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dyspnea, swollen joints. No other new significant symptoms. Has been having trouble
sleeping related to the steroids and nausea/stomach pain related to the abx.

PRIOR RHEUMATOLOGIC HISTORY

- patient admitted to MGH 1/11-1/15/23 for ~3mths R ear swelling and pain despite
multiple courses of abx. Was started on IV cefepime, vanc added later with no
improvement. Started on scheduled ibuprofen with some improvement. Infectious w/u
during admission negative. CT neg for deep space infection/abscess. Rheum ROS
completely negative. Brief rheum w/u (RF, ANA) both negative during admission.
Because of limited response to NSAIDs, switched to prednisone 40mg with taper upon
d/c.
ROS
Denies fevers, chills, night sweats, unintended weight loss, anorexia, fatigue, malaise,
headache, paresthesias, focal weakness, rash, recent URI, loss of hearing, dry eyes,
dry mouth, dyspnea, cough, chest pain, abdominal pain, nausea, vomiting, GERD,
diarrhea, constipation, dysuria, urogenital complaints.
Denies alopecia, photosensitivity, mucosal ulcerations, oral lesions, thrush, and
Raynaud’s symptoms. Denies ocular inflammation, sausage digits, nail changes,
urethritis, low back pain, personal or history of psoriasis or inflammatory bowel
disease. Denies scalp tenderness, visual changes, jaw claudication, dry cough, and
upper extremity claudication.

Negative 10-point ROS unless indicated in HPI.

Past Medical and Surgical History:
Patient Active Problem List
Diagnosis Date Noted
• Perichondritis 01/11/2023

No past surgical history on file.

Allergies:
No Known Allergies
Current Outpatient Medications:
Current Outpatient Medications on File Prior to Visit
Medication Sig Dispense Refill Last
Dispense
• azaTHIOprine (IMURAN) 50 Take 2.5 tablets 225 tablet 0 Unknown
mg tablet (125 mg total) by (outside
mouth daily. pharmacy)
• acetaminophen (TYLENOL) Take 2 tablets (650 0 Unknown
325 mg tablet mg total) by mouth (no
every 6 (six) hours pharmacy)
as needed.
• oxyCODONE 5 MG Take 0.5 tablets 5 tablet 0 Unknown
immediate release tablet (2.5 mg total) by (outside
mouth every 6 (six) pharmacy)
hours as needed.
Partial fill ok
(Patient not taking:
Reported on
3/14/2023)
• traZODone (DESYREL) 50 TAKE 1 TABLET 90 tablet 1 Unknown
MG tablet BY MOUTH (outside
NIGHTLY AT pharmacy)
BEDTIME AS

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Gen: WDWA, NAD, AAOx4

HEENT: R ear with minimal erythema of the cartilaginous portion of the R external ear.
No warmth. Able to palpate without tenderness, except for superior portion near biopsy
site. Tugging ear elicits pain. L ear normal-appearing, no ttp. No ttp of the nasal bridge.
Chest: CTAB, no w/r/r
MSK: tenderness to palpation of the PIPs with fullness noted in the MCPs, question of
synovitis. stiffness noted when ranging b/l wrists. Otherwise, exam wnl

LABORATORY
Lab Results
Component Value Date
WBC 4.81 05/16/2023
RBC 4.45 05/16/2023
HGB 12.4 05/16/2023
HCT 38.7 05/16/2023
PLT 474 (H) 05/16/2023
MCV 87.0 05/16/2023
MCH 27.9 05/16/2023
MCHC 32.0 05/16/2023
RDW 15.0 (H) 05/16/2023
MVP 8.6 05/16/2023
NRBCA 0.00 05/16/2023

Lab Results
Component Value Date
NA 139 05/16/2023
K 3.9 05/16/2023
CL 102 05/16/2023
CO2 24 05/16/2023
BUN 4 (L) 05/16/2023
CRE 0.69 05/16/2023
UCRE CREDITED: NO 02/07/2023
SPECIMEN
RECEIVED
GLU 100 05/16/2023
CA 9.3 05/16/2023
GFR 117 05/16/2023
ANION 13 05/16/2023

Lab Results
Component Value Date
ALB 4.6 05/16/2023
TBILI 0.3 05/16/2023
DBILI <0.2 05/16/2023
ALKP 69 05/16/2023
SGOT 21 05/16/2023
SGPT 15 05/16/2023
TP 7.3 05/16/2023
GLOB 2.7 05/16/2023

Lab Results
Component Value Date
ESR 8 05/16/2023
ESR 8 04/25/2023
ESR 4 04/03/2023

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C REACTIVE PROTEIN
Date Value Ref Range Status
05/16/2023 1.3 0.0 - 10.0 mg/L Final
Comment:

04/25/2023 0.3 0.0 - 10.0 mg/L Final

Comment:

04/03/2023 <0.3 0.0 - 10.0 mg/L Final

Comment:

No results found for: URICACID, URIC, UASSTN, TUUA, UUUA

COLOR
Date Value Ref Range Status
02/07/2023 COLORLESS (*) Yellow Final

CLARITY
Date Value Ref Range Status
02/07/2023 Clear Clear Final

GLUCOSE
Date Value Ref Range Status
02/07/2023 Negative Negative Final

BILI
Date Value Ref Range Status
02/07/2023 Negative Negative Final

KETONES
Date Value Ref Range Status
02/07/2023 Negative Negative Final

SPECIFIC GRAVITY
Date Value Ref Range Status
02/07/2023 1.007 1.003 - 1.035 Final

BLOOD
Date Value Ref Range Status
02/07/2023 2+ (*) Negative Final

PH
Date Value Ref Range Status
02/07/2023 6.5 4.5 - 8.0 Final

UROBILINOGEN
Date Value Ref Range Status
02/07/2023 Negative Negative Final

NITRITE
Date Value Ref Range Status
02/07/2023 Negative Negative Final

WBC

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Date Value Ref Range Status

02/07/2023 0-2 <10 /hpf Final

BACTERIA
Date Value Ref Range Status
02/07/2023 None None /hpf Final

SQUAMOUS CELLS
Date Value Ref Range Status
02/07/2023 None None /hpf Final

Latest Most
Reference Recent
Range &
Units
ANA titer Negative Negative
1/11/23
13:15
RHF <14 IU/mL <14
1/12/23
04:26

No results found for: TSPOT

HCV
Date Value Ref Range Status
04/03/2023 Nonreactive Nonreactive Final
Comment:

Immunization History
Administered Date(s) Administered
• COVID-19 Moderna Vaccine, Bivalent 09/26/2022
6mo+
• COVID-19 Moderna Vaccine, mRNA, PF 06/03/2021, 07/01/2021, 01/07/2022,
07/01/2022
• nfluenza Quadrivalent Preservative Free 01/15/2023
M

IMAGING
CT Head

Result Date: 1/16/2023

CT HEAD WITH CONTRAST, CT NECK SOFT TISSUE WITH CONTRAST
COMPARISON: None. FINDINGS: There is diffuse thickening and enhancement of
the cartilaginous right EAC as well as the cartilage of the right auricle. No fluid
collection is identified. There is no erosion of the bony EAC. There are multiple
prominent right intraparotid lymph nodes. There is a prominent enhancing right level 2
lymph node. None of these meet strict size criteria for pathology. Examination of the
right temporal bone demonstrates the mastoid bone to be well pneumatized and
aerated. There is no middle ear opacity. The ossicles are intact. The cochlea,

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semicircular canals, vestibular aqueduct, and internal auditory canal are normal in
appearance. The facial nerve describes a normal course. Examination of the left
temporal bone demonstrates the external auditory canal to be normal in appearance.
The mastoid bone is well pneumatized and aerated.There is no middle ear opacity.
The ossicles are intact. The cochlea, semicircular canals, vestibular aqueduct, and
internal auditory canal are normal in appearance. The facial nerve describes a normal
course. Examination the brain demonstrates no evidence of acute intracranial
hemorrhage, midline shift, or mass effect. The ventricles and sulci are normal in size
configuration. There are no extra-axial fluid collections. The dural venous sinuses are
patent. The nasopharynx, oropharynx, oral cavity, and larynx are unremarkable. No
significant abnormality is seen in the thyroid, submandibular, or parotid glands. The
vessels of the neck enhance normally. The lung apices are clear. No suspicious
osseous lesions are identified.

1. Thickening and enhancement of the cartilaginous right external auditory canal and
the cartilage of the right auricle. There is no evidence of fluid collection. There is
reactive lymphadenopathy in the adjacent parotid gland. 2. No other abnormality is
identified in the neck. 3. No abnormality is identified in the brain. The dural venous
sinuses are patent.

CT Neck

Result Date: 1/16/2023

CT HEAD WITH CONTRAST, CT NECK SOFT TISSUE WITH CONTRAST
COMPARISON: None. FINDINGS: There is diffuse thickening and enhancement of
the cartilaginous right EAC as well as the cartilage of the right auricle. No fluid
collection is identified. There is no erosion of the bony EAC. There are multiple
prominent right intraparotid lymph nodes. There is a prominent enhancing right level 2
lymph node. None of these meet strict size criteria for pathology. Examination of the
right temporal bone demonstrates the mastoid bone to be well pneumatized and
aerated. There is no middle ear opacity. The ossicles are intact. The cochlea,
semicircular canals, vestibular aqueduct, and internal auditory canal are normal in
appearance. The facial nerve describes a normal course. Examination of the left
temporal bone demonstrates the external auditory canal to be normal in appearance.
The mastoid bone is well pneumatized and aerated.There is no middle ear opacity.
The ossicles are intact. The cochlea, semicircular canals, vestibular aqueduct, and
internal auditory canal are normal in appearance. The facial nerve describes a normal
course. Examination the brain demonstrates no evidence of acute intracranial
hemorrhage, midline shift, or mass effect. The ventricles and sulci are normal in size
configuration. There are no extra-axial fluid collections. The dural venous sinuses are
patent. The nasopharynx, oropharynx, oral cavity, and larynx are unremarkable. No
significant abnormality is seen in the thyroid, submandibular, or parotid glands. The
vessels of the neck enhance normally. The lung apices are clear. No suspicious
osseous lesions are identified.

1. Thickening and enhancement of the cartilaginous right external auditory canal and
the cartilage of the right auricle. There is no evidence of fluid collection. There is
reactive lymphadenopathy in the adjacent parotid gland. 2. No other abnormality is
identified in the neck. 3. No abnormality is identified in the brain. The dural venous
sinuses are patent.

XR Chest Portable

Result Date: 1/13/2023

XR CHEST PORTABLE COMPARISON: None. FINDINGS: Devices/Tubes/Lines:

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None. Lungs: Normal. The lungs are clear. No focal consolidation or pulmonary
edema. Pleura: Normal. No pleural effusion or pneumothorax. Heart/Mediastinum:
Normal heart and mediastinum. Bones/Soft Tissues: Normal. No significant skeletal
abnormality.

Normal chest. ATTESTATION: I, as teaching physician, have reviewed

the images for this case and if necessary edited the report originally created by

PATHOLOGY:
R ear cartilage 2/21/23:
FINAL PATHOLOGIC DIAGNOSIS:
A-B. RIGHT EMINENCE OF TRIANGULAR FOSSA/SCAPHA, EXCISION BIOPSY:
Viable cartilage associated with focal chronic inflammation; (see note).

Note: No acute inflammation. There are no diagnostic features of a neoplasm. No

diagnostic features of vasculitis are noted. The histologic findings are not
entirely specific but may be compatible with an inflammatory process such as
perichondritis (vs resolving/evolving infection or others). Correlation with
clinical and laboratory findings may be considered; correlation may also be
needed to ensure that the biopsy is representative.

**Electronically Signed Out By MD, PHD**

Resident Pathologist:
MD

By his/her signature above, the pathologist listed as making the Final Diagnosis
certifies that he/she has personally reviewed the case and confirmed the
diagnosis. All slides and stains were of sufficient quality to establish the
diagnosis, unless otherwise stated.

PROCEDURES/ADDENDA

Mayo Tissue Flow Cytometry

Ordered Date: 2/27/2023

SPECIMEN: Right triangular fossa

DIFFERENTIAL (% OF ALL WBCs): Lymphocytes: <1%

INTERPRETATION:
Nonviable specimen with no definite B or T cells.
This sample may not be representative as very few viable lymphoid cells are
available for analysis (viability of this specimen is 11% by 7-AAD stain).

Flow cytometric assessment of the following antigens was incorporated into the
evaluation and interpretation of this specimen: CD3, CD5, CD7, CD10, CD19, CD20,
CD23, CD45, 7-AAD, surface kappa, surface lambda (11 total unique antibodies).
GENERAL IMPRESSION AND RECOMMENDATIONS:
In summary, is a 33 y.o. female w/ hx of relapsing polychondritis p/f f/u.

Overall doing well. Has been off of steroids now for ~1mth. Her recent labs off of

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slightly floppy but not warm. No other areas of tender or deformed cartilage. It is
possible that there is some residual inflammation given slightly high platelets, but can
maintain azathioprine for now. May need to escalate to additional therapies if more
evidence of inflammation.

____________________
MD, PhD

Patient Instructions
at 5/30/2023 11:30 AM
Brand Names: US
Cimzia;

Cimzia Starter Kit

Brand Names: Canada

Cimzia

Warning
Very bad and sometimes deadly infections have happened in patients who take this
drug. Most people who had these infections were taking other drugs to lower the
immune system like methotrexate or steroid drugs. If you have any infection, are
taking antibiotics now or in the recent past, or have had many infections, talk with
your doctor.
TB (tuberculosis) has been seen in patients started on this drug. These patients
were exposed to TB in the past, but never got the infection. You will be tested to
see if you have been exposed to TB before starting this drug.
Lymphoma and other cancers have happened in people who take this drug or
drugs like it. This has been deadly in some cases. Talk with the doctor.
This drug is not approved for use in children. Talk with the doctor.

What is this drug used for?

It is used to treat Crohn's disease.
It is used to treat ankylosing spondylitis.
It is used to treat plaque psoriasis.
It is used to treat some types of arthritis.
It may be given to you for other reasons. Talk with the doctor.

What do I need to tell my doctor BEFORE I take this drug?

If you are allergic to this drug; any part of this drug; or any other drugs, foods, or
substances. Tell your doctor about the allergy and what signs you had.
If you have an infection.
If you are taking any of these drugs: Abatacept, adalimumab, anakinra, etanercept,
golimumab, infliximab, natalizumab, rituximab, or tocilizumab.
This is not a list of all drugs or health problems that interact with this drug.
Tell your doctor and pharmacist about all of your drugs (prescription or OTC,
natural products, vitamins) and health problems. You must check to make sure that
it is safe for you to take this drug with all of your drugs and health problems. Do not
start, stop, or change the dose of any drug without checking with your doctor.

What are some things I need to know or do while I take this drug?
Tell all of your health care providers that you take this drug. This includes your

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doctors, nurses, pharmacists, and dentists.

You may have more chance of getting an infection. Wash hands often. Stay away
from people with infections, colds, or flu.
If you have had hepatitis B before or carry the virus, this drug can cause the virus
to become active. This can lead to very bad and sometimes deadly liver problems.
You will be tested for hepatitis B before starting this drug. You will need to watch for
signs of hepatitis while taking this drug and for several months after stopping it.
Talk with your doctor.
Talk with your doctor before getting any vaccines. Use of some vaccines with this
drug may either raise the chance of an infection or make the vaccine not work as
well.
Do not get a weakened bacteria like BCG for bladder cancer while you use this
drug. Talk with your doctor.
Have blood work checked as you have been told by the doctor. Talk with the doctor.
If you have high blood sugar (diabetes), talk with your doctor. You may be more
likely to get infections.
This drug may affect certain lab tests. Tell all of your health care providers and lab
workers that you take this drug.
Have your skin checked as you have been told by your doctor.
If you have a latex allergy, talk with your doctor. Some products have latex.
Rarely, people using drugs like this one have had nervous system problems.
Sometimes, these problems have not gone away. Call your doctor right away if you
have a burning, numbness, or tingling feeling that is not normal; change in
eyesight; dizziness; seizures; or weakness in your arms or legs.
A rare type of cancer called hepatosplenic T-cell lymphoma (HSTCL) has
happened with this drug and other drugs like it. These cases have been deadly.
Almost all cases were in people who were using drugs like this one along with
certain other drugs (azathioprine or 6-mercaptopurine). Most of the time, this
happened during treatment for Crohn's disease or ulcerative colitis. Also, most
cases were in male teenagers or young males. Talk with the doctor.
Heart failure has happened with this drug, as well as heart failure that has gotten
worse in people who already have it. Tell your doctor if you have heart disease.
Call your doctor right away if you have shortness of breath, a big weight gain, a
heartbeat that is not normal, or swelling in the arms or legs that is new or worse.
If you are 65 or older, use this drug with care. You could have more side effects.
Tell your doctor if you are pregnant, plan on getting pregnant, or are breast-feeding.
You will need to talk about the benefits and risks to you and the baby.
If you used this drug when you were pregnant, tell your baby's doctor.

What are some side effects that I need to call my doctor about right away?
WARNING/CAUTION: Even though it may be rare, some people may have very
bad and sometimes deadly side effects when taking a drug. Tell your doctor or get
medical help right away if you have any of the following signs or symptoms that
may be related to a very bad side effect:
Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or
peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble
breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth,
face, lips, tongue, or throat.
Signs of infection like fever, chills, very bad sore throat, ear or sinus pain, cough,
more sputum or change in color of sputum, pain with passing urine, mouth sores,
or wound that will not heal.
Signs of a urinary tract infection (UTI) like blood in the urine, burning or pain when
passing urine, feeling the need to pass urine often or right away, fever, lower
stomach pain, or pelvic pain.
Signs of liver problems like dark urine, tiredness, decreased appetite, upset

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stomach or stomach pain, light-colored stools, throwing up, or yellow skin or eyes.
Signs of lupus like a rash on the cheeks or other body parts, sunburn easy, muscle
or joint pain, chest pain or shortness of breath, or swelling in the arms or legs.
Very bad dizziness or passing out.
Lump in the armpit, groin, or neck.
Pale skin.
Call your doctor right away if you have a swollen gland, night sweats, shortness of
breath, or weight loss without trying.
Blood cell problems have happened, like aplastic anemia and a type of low white
blood cell count. Tell your doctor right away if you feel very tired or weak or have a
fever, chills, shortness of breath, any unexplained bruising or bleeding, or purple
"splotches" on your skin.
Certain types of skin cancer have happened in people taking this drug. Call your
doctor right away if you have a change in color or size of a mole, or any new or
changing skin lump or growth.

What are some other side effects of this drug?

All drugs may cause side effects. However, many people have no side effects or
only have minor side effects. Call your doctor or get medical help if any of these
side effects or any other side effects bother you or do not go away:
Irritation where the shot is given.
Signs of a common cold.
These are not all of the side effects that may occur. If you have questions about
side effects, call your doctor. Call your doctor for medical advice about side effects.
You may report side effects to your national health agency.

How is this drug best taken?

Use this drug as ordered by your doctor. Read all information given to you. Follow
all instructions closely.
All products:
It is given as a shot into the fatty part of the skin on the top of the thigh or the belly
area.
If you will be giving yourself the shot, your doctor or nurse will teach you how to
give the shot.
Wash your hands before and after use.
Move the site where you give the shot with each shot.
Do not give into skin that is irritated, bruised, red, infected, hard, or scarred.
Do not use if the solution is cloudy, leaking, or has particles.
This drug is colorless to a faint yellow. Do not use if the solution changes color.
Inject at least 1 inch away from where the last dose was given. If your dose has
more than 1 injection, give the injections into 2 different places at least 1 inch apart.
Do not give into skin within 2 inches of the belly button.
Throw away needles in a needle/sharp disposal box. Do not reuse needles or other
items. When the box is full, follow all local rules for getting rid of it. Talk with a
doctor or pharmacist if you have any questions.
Prefilled syringes:
Before giving the shot, let it come to room temperature. Do not heat this drug.
Throw syringe away after use. Do not use the same syringe more than one time.
Vials:
If stored in a refrigerator, let this drug come to room temperature before using it.
Leave it at room temperature for at least 30 minutes. Do not heat this drug.
This drug must be mixed with sterile water before using. The sterile water that
comes with this drug is meant for one use only. Throw away any part of the sterile
water that is not used after one use.
When making, do not shake vial.

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Use right away after mixing or you may store in a refrigerator for up to 24 hours.
When ready to inject the mixed drug, it should be at room temperature. Do not
leave any mixed drug at room temperature for more than 2 hours before using.
Throw away any part of the opened vial not used after the shot is given.

What do I do if I miss a dose?

Call your doctor to find out what to do.

How do I store and/or throw out this drug?

All products:
Store in a refrigerator. Do not freeze.
Store in the original container to protect from light.
Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
Throw away unused or expired drugs. Do not flush down a toilet or pour down a
drain unless you are told to do so. Check with your pharmacist if you have
questions about the best way to throw out drugs. There may be drug take-back
programs in your area.
Prefilled syringes:
Some products may be stored at room temperature for up to 7 days. Some may be
stored at room temperature for up to 10 days. Be sure you know how long your
drug may be stored at room temperature. Write down the date you take this drug
out of the refrigerator. If stored at room temperature and not used, throw this drug
away.
Do not put this drug back in the refrigerator after it has been stored at room
temperature.
Vials:
If needed, you may store at room temperature for up to 6 months. Write down the
date you take this drug out of the refrigerator. If stored at room temperature and not
used within 6 months, throw this drug away.
Do not put this drug back in the refrigerator after it has been stored at room
temperature.

General drug facts

If your symptoms or health problems do not get better or if they become worse, call
your doctor.
Do not share your drugs with others and do not take anyone else's drugs.
Some drugs may have another patient information leaflet. If you have any
questions about this drug, please talk with your doctor, nurse, pharmacist, or other
health care provider.
If you think there has been an overdose, call your poison control center or get
medical care right away. Be ready to tell or show what was taken, how much, and
when it happened.

Last Reviewed Date

2023-01-11
Consumer Information Use and Disclaimer
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medication information. It is not meant to be comprehensive and should be used as
a tool to help the user understand and/or assess potential diagnostic and treatment
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medications, side effects, or risks that may apply to a specific patient. It is not
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treatment of a health care provider based on the health care provider's examination
and assessment of a patient's specific and unique circumstances. Patients must
speak with a health care provider for complete information about their health,

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