Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least two of these prompts:
- Do you agree with your peers’ assessment?
- Take an opposing view to a peer and present a logical argument supporting an alternate opinion.
- Share your thoughts on how you support their opinion and explain why.
- Present new references that support your opinions.
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.
Please be sure to validate your opinions and ideas with citations and references in APA format.
What is your differential diagnosis for this patient?
Differential diagnoses for this patient include Rheumatoid Arthritis M06.9, which is an autoimmune disease that presents with the symptoms of joint pain. Joint stiffness, and joint swelling. Complaints of joint pain may include bilateral pain and occurring in the morning (Singh et al., 2019). Another possible diagnosis for this patient may include Osteoarthritis M15.0 which presents swelling of the joints, and often is associated with hard and boney areas. Psoriatic Arthritis L40.52 also presents with symptoms of joint pain, but typically there is a rash associated with the joint pain. Other known symptoms of psoriatic arthritis include sausage toes and or fingers, and onychodystrophy.
What diagnostic studies are warranted for this patient?
To narrow down the diagnosis for this patient Laboratory testing is needed, the test that needs to be done includes a CBC, CMP, ESR, CRP, ANA, RF and a urinalysis. An X ray of the affected area is also warranted (ACR Score: What Does an ACR Score Measure? – RheumatoidArthritis.org, n.d.). Due to the time period that the patient has reported symptoms I would also consider checking the patient for viruses that present with the reported symptoms. The viruses I would check for include HCV, HBV, and the human parvovirus.
What is the patient’s calculated American College of Rheumatology/European League Against Rheumatism (ACR/EULA) score?
I am unsure of the score for this patient because I do not have the results of certain test back. The scoring requires Laboratory test results that show measuring of the sedimentation rate or C-reactive proteins, which determine the amount of inflammation in the joints. The physician assessment would describe and determine the patient’s progress. The disability/functionality questionnaire assesses how much the patient is able to use their joints easily to complete ADL’s (Aringer et al., 2019).
What is the treatment for this patient?
Pharmacological treatment for this patient would include Methotrexate 7.5mg weekly. A folic acid supplement of 1mg daily could prove beneficial. The patient would be educated on side effects of both medications. The most common side effects that are reported include Gi issues, sores in the mouth and changes in the liver. Other more serious complications that should be monitored include lung and liver toxicity and bone marrow changes (Bullock et al., 2018).
Non Pharmacological treatment for this patient PT and OT. These treatments are used to help maintain and improve functionality. In additional I would also educate the patient on the use of heat and ice to help with pain and stiffness. This patient may also benefit from resting the affected joints by using compression and splinting. The symptoms of this disease can be embarrassing and can cause the patient to have self-esteem issues. It is important that resources be provided to the patient that support a healthy mental state (Bergström et al., 2021).
2- Dhara Patel
What is your differential diagnosis for this patient?
Rheumatoid Arthritis: This patient is 47 years old and has bilateral stiffness in her hands (small joint of her hands), morning stiffness lasting for more than 2 hours, and no improvement in pain with the use of Naproxen. Has a family history of RA, and she is a smoker. These are all factors that can be seen in a patient with rheumatoid arthritis (Alexander et al., 2017).
Osteoarthritis – This should be included in the differential given the stiffness in joints (although arthritis affects larger joints and unilaterally as opposed to bilaterally), along with stiffness in the morning, and she is a female. Would want to inquire about any history of fractures and menstrual history and menopause.
Carpal Tunnel Syndrome: This should be included in the differential given her presenting complaint of wrist and hand pain, and especially with her occupation and typing at work, she is at an increased risk for developing carpal tunnel syndrome. Some of the other symptoms of this could be tingling/numbness or weakness in fingers or wrists (Mayo Clinic, 2022).
Tendonitis: Given her occupation as an administrative assistant and frequent typing at work, such redundant activities can increase the risk of inflammation of tendons, leading to tendinitis and pain, so this should also be listed in the differentials.
What diagnostic studies are warranted for this patient?
Some of the diagnostic studies that would be warranted for this patient are erythrocyte sedimentation rate, c-reactive protein, rheumatoid factor, and anti-cyclic citrullinated peptide (anti-CCP) antibodies (Mayo Clinic, 2023). Erythrocyte sedimentation rate and c-reactive protein would indicate the presence of an inflammatory process in the body. Rheumatoid factor alone is not a diagnostic for Rheumatoid arthritis as it can be present in other diseases, but if both the rheumatoid factor and the anti-citrullinated protein/peptide antibody are positive, then the sensitivity and specificity of the disease are increased substantially (Chauhan et al., 2023). With advanced disease, joint involvement on plain radiographs will reveal periarticular osteopenia, joint space narrowing, and bony erosions (Chauhan et al., 2023). Erosions of cartilage and bone are considered pathognomonic findings for rheumatoid arthritis but are not specific (Chauhan et al., 2023). MRI can also be performed. Due to the varied clinical presentation and lack of universal pathognomonic testing for rheumatoid arthritis, diagnosing the disease can be challenging early in the course of the disease. Current research suggests that at least four of the following criteria for at least six weeks would classify the patient as having rheumatoid arthritis, which are morning stiffness, arthritis of three or more joints, arthritis of the hands, symmetric arthritis, elevated acute phase reactants, elevated rheumatoid factor, and radiologic evidence of rheumatoid arthritis (Chauhan et al., 2023).
What is the patient’s calculated American College of Rheumatology/European League Against Rheumatism (ACR/EULA) score?
Based on the American College of Rheumatology/European League Against Rheumatism score, this patient has a score of 4. Given the patient’s information from this scenario, she has swelling in her first, third, and fifth metacarpophalangeal joints bilaterally along with both wrist pain, no information for serology or ESR/CRP components, but her symptoms have been for more than 6 weeks.
What is the treatment for this patient?
The primary goal of treatment is to achieve long-term clinical remission and optimize quality of life with the prevention of irreversible damage to the joints (Chauhan et al., 2023). The pharmacological treatment can include Disease-modifying antirheumatic drugs (DMARDs), Non-steroidal anti-inflammatory drugs (NSAIDs), Corticosteroids, Nonbiologic DMARDs, or TNF inhibitors (Chauhan et al., 2023). In this patient scenario, this patient has tried NSAIDs without any relief. According to the ACR treatment guidelines for early rheumatoid arthritis, patients who have not taken disease-modifying antirheumatic drug (DMARD) therapy should start DMARD therapy regardless of the disease activity level, and monotherapy with methotrexate is the preferred treatment (Chauhan et al., 2023). The appropriate treatment for this patient would be Methotrexate along with a short course of steroids to help with inflammation and pain. This patient should be educated first prior to starting methotrexate in terms of its side effects such as loss of appetite, diarrhea, hair loss, and headaches along with interference in blood cells and liver so they will need to be monitored closely with blood tests (NHS, 2023). Methotrexate can also affect the lungs by causing shortness of breath, so a chest x-ray prior to starting the treatment is recommended to also rule out any active TB (NHS, 2023). For this patient, her chest x-ray from today’s visit is normal with no abnormalities. This patient should be monitored for symptom relief and to change the regimen accordingly based on response to the medication. In addition to the pharmacologic treatment, physical therapy can also be recommended to this patient, where they can work with a physical therapist to come up with an individualized exercise program that would include aerobic conditioning, resistance training, stretching, flexibility, and balance exercises (Shmerling, 2023).