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Demographics

Name: M.G

Age: 50 years old

Gender: Female

Chief Complaint (Reason for seeking health care)

“I have pain and stiffness in my joints, my wrist is swelling, especially in the morning.”

History of Present Illness (HPI)

Patient is a 50-year-old white American female diagnosed with rheumatoid arthritis (RA) 3 years ago. Reports increased joint pain, stiffness, and swelling in her hands, wrists, and knees, particularly in the morning lasting more than one hour. She describes her pain as 7/10 on most days, worsening with physical activity and cold weather. She has noticed a decrease in hand grip strength and difficulty with daily activities, such as opening jars. She has tried NSAIDs with limited relief and is concerned about the progression of her symptoms.

Allergies

No known drug allergies (NKDA).

Review of Systems (ROS)

General: Reports fatigue and weight loss of approximately 5 pounds over the last month.

HEENT: No headache, vision changes, or sore throat.

Neck: No swelling or pain

Lungs: No cough or shortness of breath.

Cardio: No chest pain, palpitations, or edema.

Breast: No tenderness or discharge.

GI: Occasional nausea, no abdominal pain, no changes in bowel habits.

M/F genital:

GU: No dysuria or frequency.

Neuro: Reports mild tingling in hands, no dizziness, or numbness

Musculo: Joint pain, stiffness, and swelling in hands, wrists, and knees

Activity: Limited by joint pain and stiffness

Psychosocial: Reports feeling anxious about worsening symptoms and the impact on daily life.

Derm: No rashes or lesions.

Nutrition: Balanced diet but reports a decrease in appetite

Sleep/Rest: Wakes up due to joint pain and stiffness, reports difficulty sleeping

LMP: Post-menopausal

STI Hx: Denies any history of sexually transmitted infections

Vital Signs

Blood Pressure: 128/82 mmHg

Heart Rate: 82 bpm

Respirations: 16 breaths/min

Temperature: 98.4°F

BMI: 26

Labs

ESR: Elevated 22mm/hour

CRP: Elevated 3.6mg/dL

Rheumatoid Factor (RF): Positive

Anti-CCP: Positive

CBC: Normal except mild anemia

Medications

NSAIDs (ibuprofen) 1200 mg tab, take by mouth 3 times a day. Reports limited relief.

Losartan Potassium/hydrochlorothiazide tab 50-12.5mg, take by mouth for a total of 1 tab daily in the evening before bed.

Past Medical History

Diagnosed with rheumatoid arthritis 3 years ago. Mild hypertension managed with medications and lifestyle changes.

Past Surgical History

Appendectomy in her 30s.

Family History

Mother with history of rheumatoid arthritis and hypothyroidism. No other significant family history.

Social History

Non-smoker, drinks alcohol socially, no illicit drug use

Health Maintenance/ Screenings

Mammogram: 11/2023, normal.

Colonoscopy: Age-appropriate, normal.

Bone density scan: Last year, normal.

Physical Examination

General: Appears in mild discomfort. Alert and oriented.

HEENT: Normocephalic, no scleral icterus, clear conjunctiva.

Neck: Supple, no lymphadenopathy.

Lungs: Clear to auscultation bilaterally.

Cardio: Regular rate and rhythm, no murmurs.

Breast: No tenderness or masses, no nipple discharge or discoloration.

GI: Soft, non-tender abdomen, normal activity in all 4 quadrants.

M/F genital:

GU: Deferred.

Neuro: Mild tingling in hands bilaterally; no focal neurological deficits.

Musculo: Bilateral swelling, tenderness, and decreased range of motion in wrists, hands, and knees. Swan neck deformity noted in some fingers.

Activity: Limited ROM by joint discomfort.

Psychosocial: Mildly anxious about prognosis.

Derm: No rashes or skin changes noted.

Diagnosis

Primary: Rheumatoid Arthritis (RA), ICD-10 Code: M06.9

Differential Diagnosis

Osteoarthritis (OA) M19.0 – Characterized by joint stiffness and pain, especially in weight-bearing joints, but often without the systemic symptoms seen in RA.

Systemic Lupus Erythematosus (SLE) M32.9 – Can present with joint pain and inflammation, but typically involves other systemic manifestations.

Psoriatic Arthritis L40.52– May involve joint pain and swelling but often accompanied by characteristic skin lesions.

ICD 10 Coding

Unspecified Rheumatoid Arthritis M06.9

Essential Primary Hypertension I10

Body mass Index BMI 26.0-26.0 adult. Z68.26

Encounter for Adult Examination with abnormal findings. Z00.01

Pharmacologic treatment plan

Initiate Disease-Modifying Antirheumatic Drug (DMARD): Methotrexate (7.5–15 mg weekly) as first-line therapy for RA. Evidence supports DMARDs for slowing disease progression and reducing joint damage (Singh et al., 2016).

Folic Acid Supplement: 1 mg daily to reduce methotrexate toxicity.

NSAID or Short-Term Corticosteroid: Naproxen 500 mg twice daily as needed for pain. Alternatively, consider a short course of prednisone for flare management (American College of Rheumatology [ACR], 2021).

Diagnostic/Lab Testing

Repeat ESR and CRP levels in 3 months to monitor treatment response.

Baseline liver function tests, renal function, and CBC prior to starting methotrexate.

Education

Educate patient on methotrexate administration, side effects, and the importance of regular lab monitoring.

Emphasize the importance of joint protection, pacing activities, and the potential benefits of physical therapy (Smolen et al., 2020).

Encourage a balanced diet rich in anti-inflammatory foods. Provide written materials.

Anticipatory Guidance

Methotrexate Toxicity Awareness: Inform the patient of methotrexate's potential side effects, including signs of toxicity such as mouth sores, unexplained bruising, fatigue, or signs of infection, as these may indicate bone marrow suppression or hepatotoxicity (American College of Rheumatology [ACR], 2021). This information is crucial because early identification of adverse effects allows for timely intervention and minimizes complications associated with DMARD therapy (Singh et al., 2016).

Lifestyle Modifications: Counsel the patient on the importance of stress management and relaxation techniques, as chronic stress can worsen inflammation and fatigue associated with rheumatoid arthritis (Smolen et al., 2020). Techniques such as mindfulness meditation and breathing exercises can help reduce perceived pain and improve quality of life for patients with chronic illnesses, including RA (Sharma & Freeman, 2018).

Joint Protection and Exercise: Educate the patient on joint protection techniques and the benefits of low-impact exercises, such as walking or swimming, which can improve flexibility and reduce stiffness. Physical activity, especially when tailored to RA patients, helps prevent joint deformities and improves overall physical functioning (ACR, 2021). Advise the patient to avoid activities that exacerbate pain and consider using assistive devices as needed to support daily activities without strain on the joints (Smolen et al., 2020).

Balanced, Anti-inflammatory Diet: Encourage the patient to maintain a diet rich in anti-inflammatory foods, such as fruits, vegetables, whole grains, and omega-3 fatty acids. Research suggests that an anti-inflammatory diet may help reduce disease activity and fatigue in RA patients (Shapiro et al., 2018). Limiting processed foods, red meats, and refined sugars is also beneficial, as these foods can exacerbate inflammation and negatively impact disease outcomes (Smolen et al., 2020).

Follow up plan

Schedule follow-up in 4 weeks to assess symptom response to treatment and any adverse effects from medications.

Continue regular monitoring per RA management guidelines (ACR, 2021).

Prescription

See Below (scroll down)

References

American College of Rheumatology. (2021). 2021 guideline for the treatment of rheumatoid arthritis. ACR.

Singh, J. A., Saag, K. G., Bridges, S. L., Akl, E. A., Bannuru, R. R., Sullivan, M. C., & McAlindon, T. (2016). 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 68(1), 1-25.

Smolen, J. S., Landewe, R., Bijlsma, J., Burmester, G., Dougados, M., Kerschbaumer, A., & van Vollenhoven, R. (2020). EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Annals of the Rheumatic Diseases, 79(6), 685-699.

Sharma, R., & Freeman, M. (2018). Mindfulness meditation in rheumatoid arthritis: A randomized controlled trial. Journal of Pain Research, 11, 1757-1765.

Shapiro, J. A., Frits, M. L., Iannaccone, C. K., & Weinblatt, M. E. (2018). Effects of anti-inflammatory diet in patients with rheumatoid arthritis. Journal of Clinical Rheumatology, 24(4), 182-186.

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)____M.G__________________________ Age 50_________

Date: _11/07/2024____

RX Methotrexate 7.5 mg Tab take by mouth once a week

SIG:

Dispense: _4__________ Refill: _11/29/2024

No Substitution

Signature:____APL________________________________________________________