RHEUMATOID ARTHRITS

Chief Complaint
“I have pain in all of my joints, a swollen left knee, and stiffness every morning.”
HPI
Janet Hobbs is a 58-year-old 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 several weeks. She presented with similar symptoms 3 months ago, at which time her drug
regimen was changed from methotrexate and NSAID therapy to her current regimen below.
PMH
RA × 6 years
S/P hysterectomy 4 years ago
HTN × 10 years
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
FH
Father died from complications after a traumatic fall at age 65. Mother died of hip fracture and
pneumonia at age 78. No siblings.
Meds
Hydrochlorothiazide 25 mg po Q AM
Norvasc 10 mg po once daily
Nabumetone 750 mg, 2 tabs po Q HS
Prednisone 5 mg, 1 /2 tab po Q AM
Methotrexate 2.5 mg, 6 tabs po once a week
Hydroxychloroquine 200 mg, 1 tab po BID
Sulfasalazine EC 500 mg, 1 tab po BID
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.
All
Penicillin (rash 25 years ago)
ROS
Swelling in left knee; decreased ROM in hands; morning stiffness every day for about 3 hours; fatigue
experienced daily during afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncopal
attacks; denies nausea, vomiting, diarrhea, loss of appetite or weight loss; reports minor visual changes
corrected with stronger prescription glasses.
Physical Examination
Gen
Pleasant, middle-aged white woman in moderate distress because of pain and swelling in left knee
VS
BP 138/80, P 82, RR 14, T 37.1°C; Wt 65.3 kg, Ht 5'6''
Skin
No rashes; normal turgor; no breakdown or ulcers
HEENT
Atraumatic; moon facies; PERRLA; EOMI; AV nicking visible bilaterally; pale conjunctiva bilaterally; TMs
intact; xerostomia
Neck/Lymph Nodes
Supple, no JVD or thyromegaly; no bruits; palpable lymph nodes
Resp
CTA
Breasts
Normal; no lumps
CV
RRR; normal S1, S2; no MRG
Abd
Soft, NT/ND; (+) BS
Genit/Rect
Deferred
MS/Ext
Hands: mild RA changes; swelling of the 3rd, 4th, and 5th PIP joints bilaterally; pain in the 3rd and 4th
MCP joints on left; boutonnière deformity of the 3rd and 4th digits bilaterally; ulnar deviation bilaterally;
decreased grip strength, L > R (patient is left-handed)
Wrists: decreased ROM
Elbows: good ROM; slight permanent contracture on right; fixed nodule at pressure point
Shoulders: decreased ROM (especially abduction) bilaterally
Hips: decreased ROM on right; atrophy of quadriceps, L > R
Knees: pain bilaterally; decreased ROM on left; effusion/edema on left
Feet: no edema; full plantar flexion and dorsiflexion; 3+ pedal pulses
Neuro
CN II–XII grossly intact; muscle strength 5/5 UE, 4/5 LE, DTRs 2/4 biceps and triceps, 1/4 patella
UA
Normal
Chest X-Ray
No fluid, masses, or infection; no cardiomegaly
Hand X-Ray
Erosion of MCP and PIP joints bilaterally; measurable joint space narrowing from previous x-ray 6
months ago
Synovial Fluid
From left knee; white cells 23.0 × 103 /mm3 , turbid in appearance
DEXA scan of hip/spine
T-score reported as –2
Assessment
58-year-old woman in moderate distress with acute flare of RA (functional class II). RA not adequately
controlled with current therapy. Patient is adherent with current medication regimen. HTN is controlled
on present therapy. DEXA scan results suggestive of osteopenia.
Labs