Rheumatoid Arthritis
Patient Presentation
Chief Complaint
"I have pain in all of my joints, a swollen left knee, and stiffness every morning."
HPI
J H is a 58 yo woman who presents to her rheumatologist with generalized arthralgias, a
swollen left knee, and morning stiffness. These symptoms have been occurring with
increasing severity for the past week. She presented with the same symptoms when she
came to clinic 2 months ago.
PMH
RA x 6 years
hysterectomy 4 years ago
HTN x 10 years
FH
Father died from complications after a traumatic fall at age 65. Mother died of hip
fracture and pneumonia at age 78.No siblings.
SH
Housewife; married for 32 years; has two grown children with no known medical
problems. Denies alcohol or tobacco use. Volunteers in the community extensively but
has been doing less in the past 2 months.
ROS
Swelling in left knee; no rash, nausea, vomiting, or diarrhea; decreased ROM in hands;
denies HA, chest pain, SOB, bleeding episodes, or syncope attacks; fatigue experienced
daily during afternoon hours; denies loss of appetite or weight loss; reports minor visual
changes corrected with stronger prescription glasses.
Meds
HCTZ 25 mg po Q AM
Norvasc 10 mg po QD
Relafen 750 mg, 2 tabs Q HS
Prednisone 5 mg, 1/2tab po QAM
Patient receives medications at a local community pharmacy. Medication profile
indicates that she refills her medications on time the first of each month.
All
Penicillin (rash 25 years ago)
PE
Gen
1
Pleasant middle-aged Caucasian woman in moderate distress due to pain and swelling in
knee
VS
BP 138/80, P 82, RR 14, T 98.8°F; Ht 66", Wt 144 lb.
Skin
No rashes; normal turgor; no breakdown or ulcers
HEENT
Atraumatic; moon facies; xerostomia
Neck/LN
Supple, no JVD or thyromegaly; no bruits; palpable lymphnodes
Chest
CTA
CV
RRR; normal S1,S2; nor m/r/g
Abd
Soft, NT/ND; (+) BS
Breasts
Normal; no lumps
GU/Rect
Deferred
MS/Ext
Hands-mild RA changes; swelling 3, 4, 5 PIP joints bilaterally; pain 3, 4 MCP joints on
left; Boutonniere deformity 3,4 bilaterally; ulnar deviation bilaterally; decreased grip
strength, L> R (patient is left-handed). Wrists-good ROM. Elbows-good ROM; slight
permanent contracture on right; fixed nodule. Shoulders--decreased ROM(especially
abduction) bilaterally
Hips—decreased ROM on right; atrophy of quadriceps, L > R
Knees-pain bilaterally; decreased ROM on left; edema on left
Feet-no edema.
Labs
Na 135 mEq/L
K 4.1 mEq/L
CI 101 mEq/L
CO2 22 mEq/L
BUN 12 mg/dL
SCr 0.8 mg/dL
Hgb 10.0 g/dL
Hct 31%
WBC 13.5 x 103/mm3
PLt 356 x l03/mm3
Ca 9.1 mg/dL
Urate 5.1 mg/dL
T. chol219 mg/dL
CK < 20 IU/L
ANA negative
2
ESR 47 mm/hour
RF positive, 1:1280
UA
Normal
Chest X-ray
No fluid, masses, or infection; no cardiomegaly
Synovial Fluid
From knee; white cells 23.0 x 103/mm3, turbid in appearance
Assessment
58 yo woman in moderate distress with acute flare of RA. RA not adequately controlled
with current therapy. Patient is adherent with current medication regimen. HTN is
controlled on present therapy.
Questions
Problem Identification
1. a. List the patient's drug-related problems.
b. What information (signs, symptoms, laboratory values) indicates the presence and
severity of rheumatoid arthritis?
c. What additional information is needed to assess the patient?
Desired Outcome
2. What are the goals of pharmacotherapy in this case?
Therapeutic Alternatives
3. What non-pharmacological modalities may beneficial to this patient?
b. What pharmacologic alternatives are available for the treatment of RA?
Optimal Plan
4. What drug, dosage form, dose, schedule, and duration of therapy are best for this
patient?
Outcome Evaluation
5. What clinical and laboratory parameters are necessary to evaluate the patient's drug
therapy?
Patient Counseling
6. What information should be provided to the patient to enhance adherence, ensure
successful therapy, and minimize adverse effects?
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