Case Study #80 Rheumatoid Arthritis
Which of the vital signs is consistent with a diagnosis of rheumatoid arthritis and why?
The patient has a temperature of 100.0 F. RA is a chronic systemic, non-infecious,
inflammatory disease that affects the synovial membranes of the joints. A fever is a
systemic manifestation of inflammation and is consistant with a diganosis of RA.
List two conditions for which the drug venlafaxine is often prescribed.
Venlafaxine (Effexor XR) is a serotonin and norepinephrine reuptake inhibitor. It
can be used to treat a number of psychiatric disorders, including unipolar major
depressive disorder and panic disorder. It is used off-label to treat neuropathic pain
in patients with diabeteic neuropathy ("Venlafaxine: Drug information", 2018).
Venlafaxine: Drug information. (2018). Retrieved from https://www-
uptodate- com.ezproxy.uvm.edu/contents/venlafaxine-drug-
information?source=see_link
Identify two abnormal findings from the physical exam that are consistent with
rheumatoid arthritis.
• Patient “appears very tired”. Fatigue and malaise are common findings with
RA.
• Lymphadenopathy. In RA, lymphadenopathy can occur in the nodes near
the affected joints.
What is the association between the "fixed nodule(s) at pressure point(s)" on the left
wrist/right elbow and a diagnosis of rheumatoid arthritis?
1 in 5 patients with RA develop subcutaneous nodules, called rheumatoid nodules.
They are most commonly seen over bony prominences, or pressure points, such as
on the elbows, knuckles, and wrists. The nodules are composed of lymphocytes and
dead cell debris and they tend to develop as the arthritic process worsens. The
nodules can be present in the acute and chronic stages of the disease. Nodules can
also develop in the valves of the heart, pericardium, pleura, spleen, and eyes.
Why is it reasonable that this patient has no stiffness, pain, or swelling in the DIP joints
of the fingers?
The DIP joints are spared in RA, this is a distinguishing characteristic that helps to
differenatiate RA from osteoarthritis. In RA, the proximal joints in the fingers (PIP
joints), hands, wrists, knees, ankles, and toes are often most involved.
Identify three abnormal lab tests in table 80.1 that are consistent with a diagnosis of
rheumatoid arthritis.
• Elevated ESR
• + Rheumatoid factor
• Elevated WBC count
Why is it entirely appropriate that the PCP has ordered a TSH test for this patient?
This patient is taking levothyroxine for hypothyrodism. Given the patient’s
symptoms of fatigue and malaise, it is appropriate to determine her serum TSH in
order to attribute these symptoms to thyroid dysfunction or possibly another
condition, such as RA. Thyroid disease is also a common differential diagnosis for a
patient presenting with symptoms of fatigue, malaise, and generalized body aches
, so even if this patient did not have a history of thyroid disease, a test for TSH level
to assess thyroid function would be considered appropriate given the symptoms.
Which of the vital signs is consistent with a diagnosis of rheumatoid arthritis and why?
The patient has a temperature of 100.0 F. RA is a chronic systemic, non-infecious,
inflammatory disease that affects the synovial membranes of the joints. A fever is a
systemic manifestation of inflammation and is consistant with a diganosis of RA.
List two conditions for which the drug venlafaxine is often prescribed.
Venlafaxine (Effexor XR) is a serotonin and norepinephrine reuptake inhibitor. It
can be used to treat a number of psychiatric disorders, including unipolar major
depressive disorder and panic disorder. It is used off-label to treat neuropathic pain
in patients with diabeteic neuropathy ("Venlafaxine: Drug information", 2018).
Venlafaxine: Drug information. (2018). Retrieved from https://www-
uptodate- com.ezproxy.uvm.edu/contents/venlafaxine-drug-
information?source=see_link
Identify two abnormal findings from the physical exam that are consistent with
rheumatoid arthritis.
• Patient “appears very tired”. Fatigue and malaise are common findings with
RA.
• Lymphadenopathy. In RA, lymphadenopathy can occur in the nodes near
the affected joints.
What is the association between the "fixed nodule(s) at pressure point(s)" on the left
wrist/right elbow and a diagnosis of rheumatoid arthritis?
1 in 5 patients with RA develop subcutaneous nodules, called rheumatoid nodules.
They are most commonly seen over bony prominences, or pressure points, such as
on the elbows, knuckles, and wrists. The nodules are composed of lymphocytes and
dead cell debris and they tend to develop as the arthritic process worsens. The
nodules can be present in the acute and chronic stages of the disease. Nodules can
also develop in the valves of the heart, pericardium, pleura, spleen, and eyes.
Why is it reasonable that this patient has no stiffness, pain, or swelling in the DIP joints
of the fingers?
The DIP joints are spared in RA, this is a distinguishing characteristic that helps to
differenatiate RA from osteoarthritis. In RA, the proximal joints in the fingers (PIP
joints), hands, wrists, knees, ankles, and toes are often most involved.
Identify three abnormal lab tests in table 80.1 that are consistent with a diagnosis of
rheumatoid arthritis.
• Elevated ESR
• + Rheumatoid factor
• Elevated WBC count
Why is it entirely appropriate that the PCP has ordered a TSH test for this patient?
This patient is taking levothyroxine for hypothyrodism. Given the patient’s
symptoms of fatigue and malaise, it is appropriate to determine her serum TSH in
order to attribute these symptoms to thyroid dysfunction or possibly another
condition, such as RA. Thyroid disease is also a common differential diagnosis for a
patient presenting with symptoms of fatigue, malaise, and generalized body aches
, so even if this patient did not have a history of thyroid disease, a test for TSH level
to assess thyroid function would be considered appropriate given the symptoms.
