NR-603 Week 7 Open Forum Discussions – Inflammatory Disorders

NR-603 Week 7 Open Forum Discussions – Inflammatory Disorders Hello Dr. and classmates, This week we learned about inflammatory disorders. There are multiple inflammatory disorders tha t are frequently seen in primary care such as rheumatoid arthritis, osteoarthritis, gout, lupus, and polymyalgia rheumatic. I have seen all of these conditions numerous times at clinical. It’s important to become familiar with the presenting signs and symptoms of each condition and the diagnostic criteria for each as well. I am still learning about all of the specifics for each condition such as the pathophysiology, risk factors, and diagnostic criteria; in clinical my preceptor always quizzing me on how to diagnose and treat these conditions. Few weeks ago we had a patient who came to the office complains of sudden onset left shoulder pain while reaching into the back seat of her car to retrieve her purse. Her mobility in the Left arm is limited for the rest of the day as she cannot reach over her head or abduct her arm. The following morning she awakens to bilateral shoulder pain now and the same decrease in mobility and range of motion experienced the previous day. She concludes that she injured her left shoulder in the car and likely slept too long on the right shoulder. She treats herself with ibuprofen 600mg tid for 2 weeks. Three weeks after the incident in the car the patient notices sudden onset swelling, pain and redness of the right wrist. She is taken to urgent care where she is diagnosed with an insect bite, treated with topical corticosteroids and a toradol injection for pain and discharged. The swelling, redness and pain travel to her upper arm, opposing arm and wrist before patient seeks out an appointment with her primary care physician. We suspected that she has inflammatory arthritis or Rheumatoid Arthritis due to the onset of symptoms as well as the transitory nature of symptoms. Lab results reveal markedly elevated ANA, CRP but no signs of infection. We made a presumptive diagnosis of Polymyalgia Rheumatica. The patient is treated conservatively with Meloxicam and a methylprednisolone taper and referred to Rheumatology for further management. Rheumatology obtains a thorough history of both the presenting illness and the patient's past medical history along with hand and wrist and shoulder joint x-rays. Patient notes that the pain is completely gone with the methylprednisolone. Advanced diagnostic lab work is also completed looking for Rheumatoid arthritis, Systemic Lupus Erythematous and Gout. Lab work comes back markedly elevated for Rheumatoid arthritis. X-rays confirm early joint destruction consistent with inflammatory arthritis. The Rheumatologist elects to start the patient on Second line therapy with Methotrexate as she feels the first line treatment, Plaquenil, will not provide pain relief nor delay joint destruction as well as Methotrexate. Biologics and their impact on patients with a history is discussed and reserved for third line treatment if Methotrexate fails. Oral steroid therapy is continued at 15mg daily until Methotrexate takes full effect. Lab work to evaluate liver and kidney tolerance of Methotrexate is conducted on a monthly basis for the first 6 months of therapy. The patient is prescribed gentle physical activity and encouraged to engage in some physical activity as tolerated every day. After her case, I started to understand how to better care for these types of conditions. Show Less