Case # C0102

20 April 2011

 Identification Information:
MS is a 52 years old women with BMI = 22.5

Chief Complaint (CC):

She referred to the rheumatologist for evaluation and diagnosis of persistence joint pain ,fatigue, malaise, and loss of appetite . She states that she initially noticed stiffness in her hand on arising in the morning but this usually improve within an hour or two . during the past two months, the joint pain and stiffness have spread to her wrists and feet

MS states that she has flare ups of joint pain that last for several days before gradually getting better . She self treated with aspirin 650 mg TID OR qid during the flare up . She also complains of constipation .

History of Present Illness(HPI):

Rheumatoid arthritis Constipation 3 months ago Migraine

 Past Medical History(PMH):

Constipation 3 months ago Migraine

Family History(FH):
MS parent is alive and in their early eighties . mother has RA and CHF , father has a history of colonic polyps . she has a brother and sister , both are alive and free from rheumatoid arthritis .

 Social History(SH):
MS is married , live with her husband , and has two grown adult daughter who are married and live nearby . she's works as secretary in civil services office . she doesn't smoke nor does she drink .

 Medication List:
Drug Regimen
Aspirin 650 mg tid or qid Oxaprozin 600 mg 2 tablets daily for the past 4 months Sumatriptan 5 mg nasal spray one spray in each nostril p.r.n as Migraine Pain relief

Indication
Joint pain

Note
She self treated with aspirin It's help her joint pain somewhat , but has not alleviated the swelling , stiffness or fatigue .

needed
Hydrochlorothiazide Hypertension

12.5 mg p.o od.

 Allergy:
She is allergic to sulfa containing medication .

Physical Examination(PE):
GEN :
WD\WN white women who appears somewhat anxious

VS :
BP- 148\88 mmHg , HR 72bpm , RR 18 rpm , T 37 .4 C , wt 137Ib Ht 5'5

SKIN:
warm and dry , normal hair distribution

HEENT :
PEERLA ; EMOI; disks are flat with no hemorrhages or exudates ; TMs are intact , nares patent, oropharynx clear .

 Physical Examination(PE): cont.

NECK :

supple without JVD , lymphadenopathy , or thyromegaly .

CHEST:

CAT without wheezes or crackels

CV:

RRR, normal S1and S2 ;no S3 OR S4

ABD : GU:

soft ,tender , RUQ pain , (+) BS , no guarding , no organomegaly deferred

RECTAL :

Guaiac negative

 EXT :
1- EXTREMETIES OF THE HAND :
Reveals bilateral soft tissue swelling , erythema ,warmth and tenderness of the second , third and fourth PIP joint of both hand ; mild erythema of the corresponding MCP joint . the DIP joint of both hands appear normal and are without tenderness . The patient complain of some stiffness and mild pain during ROM test of the wrist , there is no swelling .

2- EXTREMETIES OF THE FEET :

There is mild soft tissue swelling of the second and third MTP joint of both feet . grip strength is (+) 3\5 bilaterally . there is normal ROM of the shoulders , elbow , hips and knees . there is no swan nick or boutonniere deformity and no ulnar deviation . no subcutaneous nodules are observed on the extensor surface of the forearms or elsewhere

NEURO :
A&O to place \time\person ; DTRs 2+ throughout

 Laboratory result:
Parameter
Na K Cl Ca

Value
142mEq\L 4.2mEq\L 106mEq\L 9 mg\dl

Parameter
Mg Phos ALT AST

Value
1.9 mg\dl 3.9 mg\dl 25IU\L 28IU\L

All with normal level

12 mg\dl 1 mg\dl 12.2g\dl 40% 5200mm3 T.Billi Alb Neutrophils Bands monocyte

BUN SCr Hgb Hct WBC

0.8 mg\dl 4g\dl 60% 2% 5%

Plt Eosenophils FBG Glucose HgA1c

421,500/mm3 1% 70 MG\DL 98 mg\dl 5%

lymphocytes Anti Ds-DNA Uric acid

32% _ 5.2 mg\dl

LDL HDL ERS (westrgren)

190 mg\dl 32 48 mm\h

T. chol

245 mg\dl

TG

210 mg\dl

C- reactive protein
RF positive

1.47 mg\dl

ANA

1:1280

 Diagnostic test :
Hand X Rays :
AP views reveal soft tissue swelling about the second , third , and fourth PIP joint s of both hands . no erosions are obsored at the margins . there is no obvios osteopenia

 Problem list:
1- Rheumatoid Arthritis. 2- Constipation . 3- Migrane. 4- HTN stage 1. 5- Hyperlipidemia. 6- anxiety

1. RHEUMATOID ARTHARITIST

 Drug Related Problem ( DRP ) :

Ineffective drug
needs additional therapy

Subjective (s):

Pain in her hand , feet and wrists. Morning stiffness. Flare ups.

Objective (O):

A. Physical examination:
Examination of the hand: 1- Bilateral soft tissue swelling, erythema, warmth, and tenderness of th the second, third, and fourth PIP joints of both hands. 2- Mild erythma of corresponding MCP joints. 3- Grip strength: (+) 3/5 bilaterally. Examination of the feet: 1- Mild soft tissue swelling of the second and third MTP joints of both feet.

B. Laboratory test:
Plt 421,500/mm3 lymphocytes 32%

Eosenophils
FBG Glucose HgA1c

1%
70 MG\DL 98 mg\dl 5%

Anti Ds-DNA
Uric acid

_
5.2 mg\dl

LDL
HDL ERS (westrgren)

190 mg\dl
32 48 mm\h 1.47 mg\dl 1:1280

T. chol TG
ANA

245 mg\dl 210 mg\dl

_

C- reactive protein
RF positive

C. Diagnostic test: o Hand X-ray:

AP views reveal soft tissue swelling about the second ,third ,and fourth PIP joints of both hands. No erosions are observed at the margins .There is so no obvious osteopenia

 Assessment (a):
Six months ago the PCP prescribed for the patient naproxen 500 mg bid for two months ,the patient is partially improved as the drug only obtained modest pain relief and the patient experienced some side effect which is GI up site . Then she has been switched to Oxaprozin 600 mg 2 tablets daily due to the poor response to naproxen. The patient has experienced constipation for the past 3 months secondary to the use of the Oxaprozin

 She needs an additional drug therapy because of oxaprozin is an NSAID which they should seldom be used as monotherapy for RA; instead, they should be replaced by corticosteroids. The patient need an additional therapy, Methotrexate is the first line therapy for RA .

Oral corticosteroids (e.g., prednisone) can be used to control pain and synovitis while DMARDs are taking effect (bridging therapy).

Plan (P):

1- Therapeutic goal:
a. Short term goal:
Symptom improvement includes reduction in joint pain and morning Stiffness, longer time to onset of afternoon fatigue, and improvement in Ability to perform daily activities.

b. Intermediate term goal:

Decrease level of ESR (Westergren) 48 mm/h to normal value (0 -30 mm/h ) Reduced C-reactive protien 1.47 mg/dl , to normal value.

c. Long term goal:

Prevent and treat complications, prevent exacerbations, Reduce mortality, Prevent disease progression, Improve exercise tolerance and improve health status.

2- Pharmacological plan:
D/C aspirin 650 mg . D/C oxaprozin 600 mg Start combination drug therapy: Methotrexate ,oral: 7.5-15 mg/wk + corticosteroids (prednisone) 20mg daily for 2 weeks ,then taper the dose to 5mg daily over 3 months.

3- Non-pharmacologic therapy
Occupational therapy Physical exercise and sports can be recommended to patients with early RA; muscle strength exercises are advisable

3- Monitoring Plan:
1- Methotrexate monitoring : Prior to starting therapy :
Chest x-ray Assessment of renal and liver function, fbc and blood counts.
CRP to monitor disease activity a 3 times monthly

Ongoing Monitoring :
It is recommended that all blood counts are monitored and recorded carefully. FBC, renal function and LFTs fortnightly for 3 months and monthly thereafter FBC should be measured one week after any increase in dose. In order to monitor disease activity a 3 monthly CRP would be helpful. Always look at the mean corpuscular volume (MCV).

2- Corticosteroids monitoring:
Glucose, blood pressure : every 36 months

4- Patient Education:
Patient education and counseling are well worth the time invested because they help to reduce pain, disability, and frequency of physician visits. They represent the most cost-effective intervention for RA.

Drug information :
Improvements in arthritis and other conditions usually are first seen in 3-6 weeks. The full benefit of Methotrexate therapy may not be seen until after 12 weeks of treatment.
Methotrexate cause stomach upset, which may be avoided by taking the medication with food.

5-Follow up :
Visit the rheumatologists every three to six months to chick how the drug therapy works for the patient and relief of her symptoms. CBC with platelets, AST, and albumin monitoring every 12 months.

2. CONSTIPATION

 DRP:
Safety: Drug adverse reaction.

 Subjective:
She has only two bowel movements per week. She describes her stool as hard to pass . Slight abdominal pain and discomfort secondary to bloating.

 Objective:
Physical examination: ABD: Soft, tender, RUQ pain , (+) BS, no guarding , no organomegaly.

 Assessment:
The patient experience constipation for 3 months secondary to the use of oxaprozine 600 mg 2 tablets daily for the past four months, and the patient tried to take extra fluids to relief the symptoms as it shows no effect where she still has only two bowel movement per week . A change needed from non-selective NSAI to a selective one, to reduce the GI complications. Drug should be tacking such as Laxatives to relief the symptoms.

 Plan (P):

1- Therapeutic goals:
The goal is to relieve symptoms and restore normal bowl function

2- Pharmacological plan:
Starting a laxative to relief the symptoms. Bulk-forming agents/osmotic laxatives Methylcellulose 46 g/day

3- Non-Pharmacological therapy :
Dietary modification Patients should be advised to include at least 10 g of crude fiber. Increase magnesium hydroxide in diet (Milk of Magnesia).

4- Monitoring:
No specific monitoring

5-Patient education:
The most important aspect of the therapy for constipation for the majority of patients is dietary modification to increase the amount of fiber consumed.

6-Follow up:
Follow-up within one week to see the recent onset of constipation.

3. Hyperlipidemia

 Subjective (S): None. Objective (O) :

Plt Eosenophils FBG 421,500/mm3 1% 70 MG\DL lymphocytes Anti Ds-DNA Uric acid 32% _ 5.2 mg\dl

Glucose
HgA1c

98 mg\dl
5%

LDL HDL ERS (westrgren) C- reactive protein RF positive

190 mg\dl 32 48 mm\h 1.47 mg\dl 1:1280

T. chol TG
ANA

245 mg\dl 210 mg\dl

_

 Assessment (A) :
LDL 190 mg\dl ( very high ) TC 245 mg\dl (high ) TG 210 mg\dl (high) HDL 32 (low )
MS has abnormal lipid value . She has a high level of TC and TG due to uses of hydrochlorothiazide . She has a low HDL level due to rheumatoid arthritis . The hydrochlorothiazide should be switched to another medication to treat hypertension because it elevate TC and TG level .

 MS has risk for developing CHD within the next 10 years = 6 % from the FRAMINGHAM POINT SCORES Because of these risk facters : Hypertension, defined as blood pressure greater than 140/90 mmHg. Treat with thiazide Low HDL-cholesterol level (less than 40 mg/dL). A family history of premature CHD

 The patient has 2+ risk factors and 10-year CHD risk < 10% this is done for determine the goal of therapy .
Categorical Risk
CHD or CHD risk equivalents 10-year risk: >20% 2+ risk factors 10-year risk: 20% 0-1 risk factor <100 mg/dL

Goal for LDL-C

<130 mg/dL
<160 mg/dL

 Plan ( P) :

1-Therapeutic goal :
a. long term goal :
Prevent devolving of CHD and reduce mortality .treat hyperlipidemia and control all risk factors . Improve exercise tolerance and improve health status.

b. Intermediate term goal:

Attain the level of LDL to reach <130 mg/dL . Decrease the level of TC to reach the normal value < 200 mg\dl Decrease the level of TG to reach the normal value <150 mg\dl Increase the level of HDL to reach <40

c. Short term goal:

Treat hyperlipidemia and avoidance of ADR

2-Pharmacological plan :
Discontinue (d\c) hydrochlorothiazide Start a combination therapy. give the patient statin therapy and simvastatine 20 mg \ once daily at bed time. Give her niacin (vit. B3 ) start with low dose then titrate. Start with 500 mg at bedtime for four weeks. Further titration should be based on patient response and tolerance. Daily dose should not be increased more than 500 mg every four weeks to a maximum dose of 2 grams .

3-Non pharmacological plan :

Consider therapeutic life style change (TLC ) : A)Diet B) Exercise : We chose water exercise because it is less stress on joint because the patient has rheumatoid arthritis it well decrease the pain and stiffness for the patient and increase the blood circulation for 30 mint that will increase the activity and decrease the LDL level .

Nutrient Total fat Saturated fate Polyunsaturated fat Monounsaturated fat Carbohydrates Fiber Cholesterol Protein

Recommended intake 25-35% of total calories < 7% of total calories Up to 10% of total calories Up to 20% of total calories 50-60% of total calories 20-30 g/day < 200 mg/day 15% of total calories

4- Monitoring:
Obtain a fasting lipid panel or lipid panel . Evaluate organ system functions: Renal, Hepatic to avoid complication , adjust the dosage regimen and ADR. Liver enzyme test monitoring . ALT or AST transaminases after 3 monthes from starting the medications Monitoring for ADR like ( liver toxicity and myopathy ) test the serum creatinine kinase level (CK ) .

5-Patient education:
Educate the patient about precautions and side effects the sign and symptoms of myopathy .

Patient counseling regarding intensification of therapeutic lifestyle changes (reduced intake of saturated fats and cholesterol, increased physical activity).

6-Follow up:
Evaluate the lipid profile after 1-2 month after the statin therapy then if it's doesn't need any change in the dose regimen evaluate every 3-6 months . Evaluate liver enzyme every 3 months to avoid liver toxicity Evaluate (Ck) level for the presence of myopathy and adjustment of the dose . Obtain the CHD risk factor status .

4. Uncontrolled Hypertension
(stage I)

 Subjective: None.

Objectives:
Vital sign: BP 148/88 mmHgs .

Assessment:
MS is a 52 years-old woman with an uncontrolled hypertension (stage 1) , on hydrochlorothiazide 12.5 mg P.O OD, she has the family history risk factor of CHF (mother alive with a history of CHF) Consideration should be given to D\C hydrochlorothiazide due to the side effects and initiate other drug therapy with ACEI,ARB or BB.

 Plan

1- Goals of therapy :
a. short term goal:
Achieve BP goal to target that is <140/90 mmHg.

b. Long term goal:

Prevent heart diseases (CHF).

2-Pharmacological Plan :
Discontinue hydrochlorothiazide. Switch the patient to ACEI Fosinopril (Monopril) Initial dose: 10 mg orally once a day then Maintenance dose: 20 to 40 mg orally once a day; Daily Starting doses of ACE inhibitors should be low with slow dose titration

3-Therapeutic Alternatives :
ARBs therapy has also been shown to reduce the risk of CV or BB like Propranolol (Inderal)

Initial dose: 40 mg orally twice a day, The dose should be administered at bedtime (approximately 10 PM). Maintenance dose: 120 to 240 mg/day ;Daily

3- Non-pharmacological Plan :
Lifestyle modifications to prevent and manage hypertension: Maintain normal body weight (body mass index 18.524.9 kg/m2). Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat.

Dietary sodium reduction Reduce dietary sodium intake to no more than 100 mmol per day (2.4 g sodium or 6 g sodium chloride).
Physical activity : like slow walking at least 30 min per day, 3 times per week.

4- Follow up and monitoring:

BP response should be evaluated 2 to 4 weeks after initiating or making changes in therapy.

Once goals BP values are obtained, BP monitoring can be done every 3 to 6 months.
Close monitoring of patient is required as acute hypotension may occur at the onset of ACE inhibitor therapy. Monitoring for adverse drug effects (such as persistent cough with ACE inhibitor therapy)

Laboratory tests : monitor LDL,HDL,TG and TC (to make sure the adverse effect of HCT cleared) and the other laboratory data is within the normal ranges.

5-Patient Education:
Assess the patients understanding of the new drug and its side effects. Take the dose in the morning to avoid nocturnal dieresis.

Discuss patients concerns, and clarify misunderstandings.

Educate the patient for self-measurements of BP, which can be useful to establish effective 24 hour control. Provide specific information about the role of lifestyle changes. A careful history should be taken for alarm side effect's symptoms .

5. Migraine Headaches

 Subjective:
Occasional migraine headaches.

Objectives:
Female gender. (females are more likely to have
Migraine headaches than males)

 Assessment
MS is a 52 years-old woman with an occasional migraine headache episodes on Sumatriptan 5 mg nasal spray (Imitrex Nasal) one spray in each nostril p.r.n as needed . she has the following risk factors: Being female. Women are three times as likely to have migraines as men are. Headaches tend to affect boys more than girls during childhood, but by the time of puberty, more girls are affected. Experiencing hormonal changes. woman with migraines, may find that her headaches begin during pregnancy or menopause (Age 52).

Consideration should be given to initiate therapy with two drugs: Pain-relieving medications (taking during migraine attacks) and other Preventive medications (These types of drugs are taken often on a daily basis, to reduce the severity or frequency of migraines).

 Plan (P) :

1-Goals of therapy:
a. Short term goals:
Relive migraine pain.

b. Long term goals:

Prevent migraine attacks and reduce its frequency, control the reason of migraine headaches.

2-Pharmacological Plan:
Continue sumatriptan (Imitrex Nasal) 5mg nasal spray one spray in each nostril p.r.n Add additional therapy to prevent migraine attacks, Cyproheptadine (Periactin) an antihistamine, 4 to 8 mg orally three times a day;Daily

3- Therapeutic Alternatives:
Certain antidepressants are good at helping to prevent some migraines. Most effective are tricyclic antidepressants, such as amitriptyline (Elavil) 10 mg orally once a day at bedtime;Daily

4-Non-pharmacological Plan
Lifestyle modifications to prevent and manage migraine headaches: Muscle relaxation exercises like yoga. To get enough sleep but not oversleep. Rest and relax. Keep a headache diary. Also, the patient may try other alternative medicine like:
Acupuncture Biofeedback : This relaxation technique uses special equipment to teach you how to monitor and control certain physical responses related to stress Massage. Herbs, vitamins and minerals ; e.g. A high dose of riboflavin (vitamin B-2) also may prevent migraines by correcting tiny deficiencies in the brain cells.

 Follow up and monitoring:

Close monitoring to the patient's lab parameters. Close monitoring to the drug related adverse effects. Monitoring the drug effectiveness in relieving pain and preventing attacks.

Diagnostic test:
o Computerized tomography (CT). o Magnetic resonance imaging (MRI). o Spinal tap (lumbar puncture)

 Patient Education:
Assess the patients understanding and acceptance of the types of migraine medications and dosage. Discuss patients concerns, and clarify misunderstandings. Educate the patient about the side effects alerts. Ask the patient to rate from 1 to 10 the degree of pain and report it. Provide specific written information about the role of lifestyle including diet, physical activity, dietary supplements, and the type of food that may worsen migraine headaches

 Asses the patient compliance on medications and the food that may worsen migraine headaches. Educate the patient to try not to sneeze or blow her nose just after using the sumatriptan spray. Educate the patient to wait two hours before using a second spray, After you using sumatriptan nasal spray Inform the patient to be careful if she drive or do anything that requires you to be alert after using Cyproheptadine tablets.

6. Anxiety
Generalized anxiety disorder secondary to Rheumatoid arthritis.

 DRP:
Need additional drug therapy.

Subjectives:
Fatigue , malaise, loss of appetite. migrane headaches

Objectives:
The patient looks somewhat anxious, BP-148\88 mmHg, RUQ pain

Assessment:
MS is a 52 y.o woman reffered to a rheumatologist for evaluation and diagnosis of persistent joint pain, fatigue, malaise, and loss of appetite. MS suffers from occasional migrane headaches for which she takes sumatriptan 5 mg nasal spray. GEN: WD\WN white woman who appears somewhat anxious. VS: BP-148\88 mmHg ABD: RUQ pain. Risk factors: 1- being a female. 2- chronic health condition (RA)

Plan (P):

1- Goals of treatment :
Short term goals :
reduce and relief anxiety symptoms

Intermediate term goals :

reduce the blood pressure and relief stomach pain caused by anxiety. And reduce progression of anxiety.

Long term goals :

prevention of anxiety symptoms

2- Pharmacological plan:
Treatment with buspirone is best started at 10-15 mg/day in 2-3 divided doses; this dose can be increased, if required, to a target of 15-30 mg/day in 2-3 divided doses. Rarely, higher doses, of up to 45-60 mg/day, may be needed

4- Therapeutic alternatives:
Alprazolam start with 0.25 0.5 mg 3 times daily titrate the dose up ward ;usual maximum dose is 4mg \day Dose reduction : decrease the daily dose by 0.25 mg every 2 -3 days

5-Non pharmacological plan:

Talk to a therapist. Advise the patient to relax, go out, and talk to relatives or friends. Advise the patient to read self help books and looking after her physical and mental well-being.

 Monitoring:
Monitor for the symptoms of anxiety and mental status.

 Patient education:
Counsel and Assess the patients understanding of the drug and its side effects Discuss patients concerns, and clarify misunderstandings Taking the medication with or without meals

 Follow up:
Visit after 4 weeks from initiate the drug.

Thank you..
Bushra Al- yahya Ghadah Al-ajmi Joud Al-fraih Rehab Al-shammari Sara Al-belal Yasmen kamakhi