Rheumatoid Arthritis Disease Case Studies

A 34 yo F with history of smoking presents with joint pain.

Questions to Ask

• Main question about joint pain: is joint pain inflammatory or not?
• Pertinent other questions about joint pain:
  • Duration of symptoms?
  • Joints involved?
  • Joint count?
  • Joint stiffness in the morning?
• Any other body systems involved?
• Inquire about infectious risk factors for parvo, hepatitis, TB

History & Physical Exam

History

• Bilateral hand stiffness in the morning >2 hours with joint swelling in MCPs, PIPs, wrist
• Progressive worsening for weeks to months
• Feels like walking on rocks in the morning
• Progressive shortness of breath, nonproductive cough

Physical Exam

• Warm, swollen wrists
• MCPs and PIPs tender to touch with synovial thickening and bogginess
• Lung crackles

Diagnostic Workup

• Recommended labs: CBC with diff, CMP, CRP, ESR, RF, CCP, hepatitis B/C serologies, Quant TB
• Recommended imaging: hand and feet x-rays – 3 views
• If any signs or symptoms of other organ involvement, assess accordingly:
  • Pulmonary function tests
  • AP/lateral chest x-ray +/- transthoracic echo
• Even if CXR unremarkable, would order CT chest without contrast interstitial lung disease (ILD) protocol to assess for inflammatory lung disease

Referrals

• Refer to rheumatology

Treatment & Management

• Can start systemic steroids (dose of prednisone 15-20 mg per day with a taper over 4-6 weeks) if patient requires symptom relief
• Consider methotrexate if no contraindications
  • Consider starting dose of PO 10-15 mg weekly with daily folic acid 1 mg PO
• Monitor:
  • With steroids: blood sugars, blood pressure, signs of volume overload
  • With methotrexate: pregnancy test in females of reproductive age, CBC with differential, renal function and liver function tests at baseline and every 3 months