HPI Analise Schaefer is a 54-year-old African-American woman
HPI Analise Schaefer is a 54-year-old African-American woman who… HPIAnalise Schaefer is a 54-year-old African-American woman who presents to rheumatology clinic with complaints of generalized arthralgias, fatigue, and morning stiffness. She has a 13-year history of RA currently treatedwith methotrexate. She reports worsening in her symptoms over the past 6 months.PMHRA × 13 yearsHeart failure with reduced ejection fraction (currently NYHA class III)FHFather is alive and being treated for hypertension and osteoarthritis. Mother is alive and being treated for severe RA. Two siblings with no major health concerns.SHTax accountant; married for 25 years; heterosexual, sexually active, monogamous. Denies tobacco or illicit drug use. Drinks one to two glasses of wine per week.MedsMethotrexate 2.5 mg, six tablets (15 mg) PO once a week Folic acid 1 mg PO once dailyLisinopril 40 mg PO once dailyMetoprolol succinate 100 mg PO once daily Spironolactone 25 mg PO once dailyFurosemide 40 mg PO once dailyPatient receives medications at a local community pharmacy. Medication profileindicates that she refills her medications on time on the first of each monthAllergies Sulfonamides (hives)ROSComplains of swelling and pain in both hands; reports decreased ROM in hands and wrists; has morning stiffness every day for about 2 hours and fatigue daily during the afternoon hours; denies HA, chest pain, bleeding episodes, or syncope; no nausea, vomiting, diarrhea, loss of appetite, or weight loss.PEGenAfrican-American woman in moderate distress because of pain, swelling, and fatigue related to arthritisVSBP 118/76 mm Hg, P 62 bpm, RR 14, T 37.1°C; Wt 65 kg, Ht 5’6”SkinNo rashes; normal turgor; no breakdown or ulcers; no subcutaneous nodulesHEENTNormocephalic, atraumatic; moist mucous membranes; PERRLA; EOMI; pale conjunctiva bilaterally; TMs intact; no oral mucositisNeck/Lymph NodesNeck supple, no JVD or thyromegaly; no thyroid bruit; no lymphadenopathyChest:CTABreasts:DeferredCV:RRR; normal S1, S2; no MRGAbd: Soft, NT/ND; (+) BSGenit/Rect:DeferredMS/Ext:Total of 16 tender and 16 swollen joints bilaterallyHands: swelling and tenderness on palpation of second, third, fourth, and fifth PIP and MTP joints bilaterally; decreased grip strength, L > R (patient is left-handed)Wrists: decreased ROMElbows: good ROMShoulders: decreased ROM (especially abduction) bilaterallyHips: good ROMKnees: good ROM, no pain bilaterallyFeet: no obvious swelling of MTP joints; full plantar flexion; reduced dorsiflexion; 2+ pedal pulsesNeuroCN II-XII intact; muscle strength 4/5 UE, 4/5 LE, DTRs 2+ throughoutLabs: Na 135 mEq/L K 4.1 mEq/L Cl 101 mEq/L CO2 22mEq/L BUN 12 mg/dL SCr 0.8 mg/dL Glu 103 mg/dLHgb 10.8 g/dLHct 31%WBC 6.2 × 103/mm3 Plt 356 × 103/mm3 Ca 9.1 mg/dL Urate 5.1 mg/dL TSH 0.74 mIU/LAST 15 IU/LALT 12 IU/LAlk phos 56 IU/L T. bili 0.8 mg/dL Alb 4.2 g/dL HbsAg (-) Anti-HCV (-)CK <20 IU/LANA negativeWes ESR 60 mm/hr RF (+) 50 U/mL Anti-CCP 70 EU aPTT 31 seconds INR 1.0 UA: NormalChest X-Ray:No fluid, masses, or infection; no cardiomegalyHand X-Ray:Multiple erosions of MCP and PIP joints bilaterally; measurable joint space narrowing from previous x-ray 1 year agoDAS 28:6.2 today; 3.0 one year agoAssessment1. RA2. HeartfailureSCollect Information1.a. What subjective and objective information indicates the presence of rheumatoid arthritis?1.b. What additional information is needed to fully assess this patient's rheumatoid arthritis?Assess the Information2.a. Assess the severity of rheumatoid arthritis based on the subjective and objective information available.2.b. Create a list of the patient's drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence.2.c. What economic, psychosocial, cultural, racial, and ethical considerations are applicable to this patient?Develop a Care Plan3.a. What are the goals of pharmacotherapy in this case?3.b. What nondrug therapies for rheumatoid arthritis might be useful for thispatient?3.c. What feasible pharmacotherapeutic alternatives are available for treating rheumatoid arthritis?3.d. Create an individualized, patient-centered, team-based care plan to optimize medication therapy for this patient's rheumatoid arthritis and other drug therapy problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy.3.e. What alternatives would be appropriate if the initial therapy for rheumatoid arthritis fails or cannot be used?Implement the Care Plan4.a. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?4.b. Describe how care should be coordinated with other healthcare providers. Follow-up: Monitor and Evaluate5.a. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?5.b. Develop a plan for follow-up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.SELF-STUDY ASSIGNMENTS1. Create a list of clinically significant drug interactions for NSAIDs and DMARDs, including methotrexate.2. Compare the biologic agents used to treat RA with respect to drug class, route of administration, efficacy, contraindications, and side effectsHealth Science Science Nursing HSA MISC
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