Download New Onset Rheumatoid Arthritis with Pre-existing

Inflammatory Arthritis
Case 7 : Jayna
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Objectives
When working with CPP, you will be able to:
 Identify inflammatory versus non-inflammatory
signs and symptoms
 List 3 assessment tools that may be useful
 Conduct a joint count examination
 Identity appropriate investigations
 Appropriate access of RACE line
 Appropriate Self Management
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Sore Hands and Feet
Jayna is a 55 year old Lawyer
4 week history of soreness in her hands and feet that is
increasing over time. She says the balls of her feet hurt with
walking and her hands hurt when she is gripping or
squeezing. She has noticed some swelling over her knuckles
(MCP’s) and in her fingers (PIP’s).
Her past history includes right thumb and left knee
osteoarthritis diagnosed 5-7 years ago and controlled with
occasional medication, stretching and heat.
She is finding it difficult to complete her daily work and
home activities.
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What are your Key Questions?
 How do you determine if
this is osteoarthritis or
rheumatoid arthritis?
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Common Patient History for MSK Complaints
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Joint Pain Questions
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History
Jayna states that her pain is constant and present
with activity and at rest. She has noticed morning
stiffness especially in her hands and it often lasts
> 4hours. She rates her pain as 7/10 and has
noticed that the joints in her hands and feet are
warmer to the touch than usual.
She is having some swelling in her hands and feet
and describes her hands as little sausages.
She feels very fatigued and blames this on stress
at work.
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Osteoarthritis comparison to Inflammatory
Arthritis
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Physical Exam
 What physical examination techniques would you use?
We found:
-Positive swollen tender joints
- 6 left hand ( MCP & PIP)
- 7 right hand ( thumb, MCP and PIP)
- Right foot ( 4 Joints)
-Active Range of motion is limited by a feeling of
resistance and soft tissue compression
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Pain and Function
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Joint Count
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Differental Diagnosis by Joint Count
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Management Tools
 How would you determine medication type and dose to
be appropriate ?
We used:
a) Consider DMARD’s
b) Screen for medical safety
c) Progress for symptom relef
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What is best Management
 Ruth-Ann has mild to moderate osteoarthritis likely
in the patellar and medial compartments
 Her pain is improving but she is hesitant to
continue with activity for fear of flaring her
symptoms
 Best Practice would focus on:
 Medications
 Rehabilitation and Exercise
 Patient Education and Self- Management
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Medication Advice
Starting a DMARD
- Hydroxychloroquine 200-400 mg once daily
- Monitor Kidney and Liver function
- Adverse Effects
- - May cause drowsiness, nausea, or night diarrhea.
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Follow-Up
 Monitor and Manage
 Swelling
 Pain
 Function
 Enhance Education
 Promote Self-Management
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Goal Setting
 Jayna is committed to reducing her stress as she
has been told that her BP is borderline for
medication.
 She has not had a flu shot for 5 years but states
that she will take your advice and get one this
year.
 She has been told that she has osteopenia and
wants to continue with walking program.
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Key Resources for your patients
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Clinical Impression
 New onset of Rheumatoid Arthritis symptoms
including swelling, stiffness and pain.
 Pre-existing thumb OA and Knee OA are stable
but add another dimension to the assessment.
 The patient is reluctant to start Dmard’s but
appreciates the promise of avoiding surgery down
the road.
 Her fatigue has worsened since her joint swelling
bega.
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Key Clinical Information
 What are the key criteria for Rheumatoid Arthritis?
 Morning Stiffness greater than 30 min.
 Constant Pain improved with activity
 Recurrent episodes
 May lead to bony deformity and decreasing function
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Summary
When working with Rheumatoid Arhtritis Osteoarthritis, it
is important to:
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Identify the differences between inflammatory and
non-inflammatory joint disease
Focus on low impart dance type movement
Focus on patient self management for lifestyle
factors
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References
 Arthritis Resource Guide, Arthritis .ca
 Guidelines and Protocols Advisory Committee
 Bcguidelines.ca
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Thank You
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