During the examination, Mom stated that they first noticed his worsening symptoms during soccer last fall when he would sit out of games due to pain. They also noted that when he got up in the morning, he walked like an old man. Dillion said he had been feeling stiff and achy for a while now, but it got worse when he tried to run or kick a ball. He also reported pain with writing in school, stating that his fingers got sore, and he had to stop frequently due to pain. The family reported that mom had a sister with Lupus. On exam, the rheumatologist found swelling in his right ankle with decreased range of motion, swelling in both knees, swelling in both elbows with flexion contractures, and swelling in multiple MCPs and PIPs of both hands. He had no hair thinning, rashes, oral ulcers, bleeding, or bruising. The remainder of his exam was normal.

Treatment recommendations included Dillion starting treatment with methotrexate, to control his body’s inflammatory response and a prescription for naproxen for pain and swelling. Risks and benefits of these medications were explained. Dillion was also prescribed folic acid to take the day after taking methotrexate to minimize side effects. Methotrexate should be taken once a week. Additional labs were drawn to rule out other connective tissue diseases and to get baseline lab values before starting methotrexate. MRIs of Dillion’s knee and hand were ordered.

Monitoring labs will be performed every 2 to 3 months to assess for drug toxicity of methotrexate. Referral to an ophthalmologist for evaluation for uveitis, a kind of arthritis in the eyes, was given. A 1-month follow-up visit was scheduled. Since the new diagnosis would affect Dillion and his family in many ways, an appointment with a clinical social worker was recommended. Due to multiple physical limitations noted on history and exam, a referral was made for physical therapy (PT) and occupational therapy (OT) assessments and outpatient therapies.