Treating patients with Rheumatoid Arthritis from an ARNP perspective
- A 50-year-old woman with rheumatoid arthritis (RA) presents to the office with what she describes as a “flare up”. How do you proceed with the work-up? Include a history and review of systems, diagnostic testing, treatment options for exacerbated RA, and patient education.
- You are the provider,What additional questions should you ask the patient and why?
- What should be included in the physical examination at this visit?
- What are the possible differential diagnoses at this time?
- What tests should you order and why?
- How should this patient be managed?
Students are expected to:
- Post an initial substantive response(min250) of to each questions as an FNP. Use Diagnostic Reasoning to answer each question.
- Please be sure to validate your opinions and ideas with in text citations and references in APA format.
- References and citations should conform to the APA 6th edition.
- Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.
- The peer postings should be at least one paragraph (approximately100 words)
In this week’s discussion scenario, a 50 year old woman presents at my office complaining of a flare up of her rheumatoid arthritis. Evaluation of this patient will involve a history and physical and labwork. An important part of the history taking involves identifying the trigger. Flare ups can be caused by over exertion, poor sleep, stress, or infective processes. If the cause is identifiable, symptoms may resolve on their own. Other questions may involve duration, nature, and severity of symptoms as compared to the patient’s baseline or previous flare ups (Watson, 2016). The questions should sound like the following:
What symptoms are you having?
Where is your pain?
Have you noticed increased swelling?
Which joints are affected?
What precipitated this flare up?
How long has this episode been going on?
What have you tried to relieve it?
How does this episode compare to previous episodes?
Have you been sick, under increased stress, changed your diet or activity, or started new medication?
The physical exam of this patient should focus on identifying increased swelling of affected joints and identifying newly affected joints (Wasserman, 2011). ANA, RF, anti-CCP, sed rate, and c reactive protein are all labs associated with rheumatoid arthritis. C reactive protein and erythrocyte sedimentation rate are both indicative of bodywide inflammation processes. Often these two tests will be elevated during flares (Dunkin, 2018).
Pharmacological treatment of flare ups can take several forms. Patients already on DMARDs like methotrexate or corticosteroids may benefit from increased doses of these medicines. NSAIDS, steroids for patients not already receiving them, and other pain relievers like opioids and tramadol may be used to decrease swelling, manage pain, and help end the flare (Venables, O’Dell, Romaine, 2018). Patients will also benefit from rest and limited exertion. Often times, flares with definable triggers will end on their own, however flares without triggers will often require medication management and possible long term medication changes (Watson, 2016).
In general, education of RA patients should include appropriate balancing of rest and exercise, smoking and alcohol avoidance, medication compliance, and nutrition (Venables, O’Dell, Romaine, 2018). Patients should also be taught to identify and avoid their triggers, act early rather then later in a flare up, and attempt to mitigate stressors. Also, they should be taught both pharmacological intervention like NSAIDS and nonpharmacological interventions like heat and rest.
One important point for a provider to remember when dealing with patients c/o RA flares, is that the flare may not always present in physical exam or labwork. Providers need to listen to patient symptoms as weel and treat accordingly. Early intervention in flare ups may help slow bone damage in the long run.
Dunkin, M. (2018, January 1). Lab test guide. Retrieved from https://www.arthritis.org/living-with-arthritis/to…
Venables, P., O’Dell, J., & Romain, P. (2018, October 1). Rheumatoid arthritis overview. Retrieved from https://www.uptodate.com/contents/rheumatoid-arthritis-treatment-beyond-the-basics.
Watson, S. (2016, February 1). Understanding RA flares. Retrieved from https://www.arthritis.org/living-with-arthritis/pain-management/flares/ra-flare-up-severity.php.
Wasserman, A. (2011). Diagnosis and management of rheumatoid arthritis. American Family Physician, 84(11): 1245-1252. Retrieved from https://www.aafp.org/afp/2011/1201/p1245.html.
Discussion Question: A 50-year-old woman with rheumatoid arthritis (RA) presents to the office with what she describes as a “flare
up”. How do you proceed with the work-up? Include a history and review of systems, diagnostic testing, treatment options for
exacerbated RA, and patient education.
Rheumatoid arthritis (RA) is a chronic systemic immune-mediated, inflammatory disease that mainly impacts joints
(Perpétuoet al., 2017). If left untreated, RA will lead to joint destruction and bone erosion. Therefore, the first questions would
be directed at determining the onset of the disease and previous treatment. Dunphy, Winland-Brown, Porter, & Thomas
(2015) write, “If left untreated, however, as the disease progresses over time, recurrent pain and swelling in both small and
large peripheral joints form the subjective picture that is ultimately associated with diminished activity and a downward spiral
of worsening pain and immobility” (p. 962). Questions should include: Is there any situation or activity that relieves or
diminished the pain? What, if anything has been done to relieve the pain, and what was the response? Does anything seem to
trigger the pain or make it worse? Because RA can become extraarticular and affect nonarticular organs, the ROS should
include more focused questions for organs that can typically be affected. The eyes, skin, lungs, heart, kidneys, neurologic,
hematologic, spleen, and peripheral vasculature can all be affected as the disease progresses (Venables & Maini, 2017).
Diagnostic testing for this patient would include a CBC with platelet count, CMP, CRP, and ESR. The ESR and CMP may be
helpful in establishing the level of disease activity (especially for future care/trending). The CBC to monitor for anemia of
chronic inflammation. An elevated platelet count may be indicative of inflammation and the CMP to monitor renal function
and albumin level (Moreland & Cannella, 2018). The current pharmacologic treatments are disease-modifying anti-rheumatic
drugs (DMARDs) for long term control and nonsteroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids, to help control
symptoms until DMARDs take effect (Cohen & Mikuls, 2018). Flares may be treated by starting oral glucocorticoid therapy or
increasing the current dose for patient already taking with the intent of reducing dose when the flare has subsided (Moreland
& Cannella, 2018). Patient education should include the goal of treatment regarding quality of life and maintenance of
functional ability. Medication adherence and follow up appointments are paramount. The patient should be informed of
treatment risk vs. benefits and the fact that the goal of treatment is disease control (Cohen & Mikuls, 2018).
Cohen, S., & Mikuls, T. R. (2018). Initial treatment . In J. R. O’Dell (Ed.), Initial treatment of rheumatoid arthritis in adults. Retrieved
Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care the art and science of advanced practice
nursing (4th ed.). [VitalSource ]. Retrieved from https://bookshelf.vitalsource.com/#/books/97803234…
Moreland, L. W., & Cannella, A. (2018). General principles of management . In J. R. O’Dell (Ed.), General principles of
management of rheumatoid arthritis in adults. Retrieved from https://www.uptodate.com
Perpétuo, I. P., Caetano-Lopes, J., Rodrigues, A. M., Campanilho-Marques, R., Ponte, C., Canhão, H., … Fonseca, J. E. (2017).
Methotrexate and low-dose prednisolone downregulate osteoclast function by decreasing receptor activator of nuclear
factor-κβ expression in monocytes from patients with early rheumatoid arthritis. RMD Open, 3, 1-8. http://dx.doi.org
Venables, P., & Maini, R. N. (2017). Clinical manifestations. In J. R. O’Dell (Ed.), Clinical manifestations of rheumatoid arthritis.
Retrieved from https://www.uptodate.com/