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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Identify signs and symptoms of rheumatoid arthritis (RA) and assess disease severity and prognosis.

  • Recommend appropriate non pharmacologic therapy for adjunctive management of RA.

  • Recommend evidence-based, patient-specific analgesic, anti-inflammatory, and disease-modifying drug therapy for patients with RA.

  • Develop an evidence-based, patient-specific monitoring plan to assess disease progress and evaluate the safety and efficacy of medication therapy.

  • Educate patients and their families about the medications used to treat RA.

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PATIENT PRESENTATION

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Chief Complaint

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“I am still very achy, I feel exhausted, and I am having a hard time getting going in the morning.”

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HPI

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Analise Schaefer is a 44-year-old African-American woman who presents to rheumatology clinic with complaints of generalized arthralgias, fatigue, and morning stiffness. She presented with similar symptoms 3 months ago, at which time she was started on naproxen and oral methotrexate. She reports a slight improvement in her symptoms relative to her visit 3 months ago.

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PMH

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  • RA (moderate disease activity with features of poor prognosis) × 3 months

  • Latent tuberculosis infection

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FH

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Father is alive and being treated for hypertension and osteoarthritis. Mother is alive and being treated for severe RA. Two siblings with no major health concerns.

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SH

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Tax accountant; married for 15 years; heterosexual, sexually active, monogamous. Denies tobacco or illicit drug use. Drinks one to two glasses of wine per week.

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Meds

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  • Naproxen 500 mg PO twice daily

  • Methotrexate 2.5 mg, six tablets (15 mg) PO once a week

  • Folic acid 1 mg PO once daily

  • Patient receives medications at a local community pharmacy. Medication profile indicates that she refills her medications on time the first of each month.

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All

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Sulfonamides—hives

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ROS

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Complains of swelling and pain in both hands; reports decreased ROM in hands and wrists; has morning stiffness every day for about 2 hours and fatigue daily during the afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncope; no nausea, vomiting, diarrhea, loss of appetite, or weight loss.

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Physical Examination

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Gen
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Caucasian woman in moderate distress because of pain, swelling, and fatigue related to arthritis

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VS
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BP 118/76 mm Hg, P 82 bpm, RR 14, T 37.1°C; Wt 65 kg, Ht 5′6″

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Skin
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No rashes; normal turgor; no breakdown or ulcers; no subcutaneous nodules

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HEENT
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Normocephalic, atraumatic; moist mucous membranes; PERRLA; EOMI; pale conjunctiva bilaterally; TMs intact; no oral mucositis

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Neck/Lymph Nodes
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