CASE LEARNING OBJECTIVES
Discuss the comorbidities associated with rheumatoid arthritis (RA)
Recognize the typical clinical presentation of RA
Create treatment goals for a patient with RA arthritis on the basis of global disease activity
Compare and contrast the available pharmacotherapeutic options, selecting the most appropriate regimen for a given patient
Propose a patient education plan that includes nonpharmacologic and pharmacologic treatment measures
Formulate an initial prescreening and a long-term monitoring plan to evaluate the safety and efficacy of a therapeutic regimen designed for an individual patient with RA
"I'm stiff and my joints are swollen."
History of Present Illness
Ching Li is a 55-year-old postmenopausal woman presenting to the rheumatologist for evaluation and treatment of RA. CL presented to her primary care physician 3 months ago with complaints of symmetrical joint pain in her hands and feet and morning stiffness lasting more than an hour. She tried ibuprofen followed by naproxen for about 2 months with limited pain relief. During a follow-up visit with her primary care physician approximately 1 month ago, naproxen was discontinued and low-dose corticosteroids were initiated. The corticosteroids have helped joint discomfort partially, but have not had an impact on joint swelling. She reports significant difficulty with dressing (especially buttons, zippers, and tying her shoes) and meal preparation. She has experienced progressive morning stiffness, now lasting for 2–3 hours daily. She reports that she feels down, but does not understand why. Her husband passed away 3 years ago and, in her opinion, she dealt with her husband's passing immediately after his death.
Peptic ulcer disease diagnosed 7 months ago
Blood transfusion following C-section in China 30 years ago
Father had CAD and died of MI at age 82. Mother died at age 70 from hepatocellular carcinoma. Her only brother has dyslipidemia and hypertension. Daughter is alive and well.
CL, a homemaker, moved to the United States from China to live with her daughter 3 years ago after her husband died. She speaks Mandarin and English. Her husband was employed by an international brokerage firm prior to his death and she has health insurance/prescription coverage available as part of his employment benefits.
(+) Tobacco 1 ppd × 40 years; (−) alcohol or illicit drug use
Allergies/Intolerances/Adverse Drug Events
Hydrochlorothiazide 12.5 mg PO daily
Prednisone 5 mg PO daily in the morning
Lansoprazole 30 mg PO daily