3. List and briefly discuss the other types of bone and joint disorders besides rheumatoid arthritis.

4. Following a review of the laboratory tests, serum ALT and AST tests were performed. What is the reasoning
behind this? What medications does the patient currently take that necessitate this monitoring?
$3. Answer the questions at the end of the activity Subjective Chief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning." HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks. She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate and NSAID therapy to her current regimen below. PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age 78. No siblings. SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco use. Volunteers in the community extensively, but has been doing less in the past 2 months.$
Transcribed Image Text:3. Answer the questions at the end of the activity Subjective Chief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning." HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks. She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate and NSAID therapy to her current regimen below. PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age 78. No siblings. SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco use. Volunteers in the community extensively, but has been doing less in the past 2 months.
Transcribed Image Text:Meds: Hydrochlorothiazide 25 mg PO Q AM, Norvasc 10 mg PO once daily, Nabumetone 750 mg = 2 tabs po Q HS, Prednisone 5 mg = 1/2 tab po Q AM, Methotrexate 2.5 mg = 6 tabs po once a week, Hydroxychloroquine 200 mg = 1 tab po BID, Sulfasalazine EC 500 mg = 1 tab po BID, Folic acid 1 mg PO once daily. The patient receives medications at a local community pharmacy. The medication profile indicates that she refills her medications on time on the first of each month. All: Penicillin (rash 25 years ago) ROS: Swelling in the left knee; decreased ROM in hands; morning stiffness every day for about 3 hours; fatigue experienced daily during afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncopal attacks; denies nausea, vomiting, diarrhea, loss of appetite or weight loss; reports minor visual changes corrected with stronger prescription glasses. Objective PHYSICAL EXAMINATION Gen: Pleasant, middle-aged white woman in moderate distress because of pain and swelling in left knee VS: BP 138/80, P 82, RR 14, T 37.1°C; Wt 65.3 kg, Ht 5'6" . . Skin: No rashes; normal turgor; no breakdown or ulcers HEENT: Atraumatic; moon facies; PERRLA; EOMI; AV nicking visible bilaterally; pale conjunctiva bilaterally; TMs intact; xerostomia . Neck/Lymph Nodes: Supple, no JVD or thyromegaly; no bruits; palpable lymph nodes Chest: CTA Breasts: Normal; no lumps CV: RRR; normal S1, S2; no MRG Abd: Soft, NT/ND; (+) BS Genit/Rect: Deferred LABORATORY EXAMINATION TABLE 96-1 Lab Values Na 135 mEq/L K4.1 mEq/L Cl101 mEq/L CO₂ 22 mEq/L BUN 12 mg/dL SCr 0.8 mg/dL Glu 103 mg/dL MS/Ext: Hands: mild RA changes; swelling of the 3rd, 4th, and 5th PIP joints bilaterally; pain in the 3rd and 4th MCP joints on left; boutonnière deformity of the 3rd and 4th digits bilaterally; ulnar deviation bilaterally, decreased grip strength, L > R (patient is left-handed) Wrists: decreased ROM Elbows: good ROM; slight permanent contracture on right; fixed nodule at pressure point Shoulders: decreased ROM (especially abduction) bilaterally Hips: decreased ROM on right; atrophy of quadriceps, L > R Knees: pain bilaterally; decreased ROM on left; effusion/edema on left Feet: no edema; full plantar flexion and dorsiflexion; 3+ pedal pulses Neuro: CN II-XII grossly intact; muscle strength 5/5 UE, 4/5 LE, DTRS 2/4 biceps and triceps, 1/4 patella Hgb 10.0 g/dl Hct 31% WBC 13.0 x 10/mm³ Plt 356 x 10³/mm³ Ca 9.1 mg/dl Urate 5.1 mg/dL TSH 0.74 mIU/L AST 15 IU/L ALT 12 IU/L Alk phos 56 IU/L T.bili 0.8 mg/dL Alb 4.2 g/dL HbsAg (-) Anti-HCV (-) CK <20 IU/L ANA negative Wes ESR 47 mm/h RF (+) 1:1,280 Anti-CCP (+) aPTT 31 sec INR 1.0 Fasting Lipid Profile: T. chol 219 mg/dL LDL 106 mg/dl HDL 50 mg/dL TG 150 mg/dl. UA: Normal Chest X-Ray: No fluid, masses, or infection; no cardiomegaly Hand X-Ray: Erosion of MCP and PIP joints bilaterally; measurable joint space narrowing from previous x-ray 6 months ago Synovial Fluid: From left knee; white cells 23.0 x 103 /mm³, turbid in appearance DEXA scan of hip/spine: T-score reported as -2

Question

3. List and briefly discuss the other types of bone and joint disorders besides rheumatoid arthritis.

4. Following a review of the laboratory tests, serum ALT and AST tests were performed. What is the reasoning
behind this? What medications does the patient currently take that necessitate this monitoring?

3. Answer the questions at the end of the activity
Subjective
Chief Complaint: “I have pain in all of my joints, a swollen left knee, and stiffness every morning."
HPI: Janet Hobbs is a 58-year-old woman who presents to her rheumatologist with generalized arthralgias, a swollen left
knee, and morning stiffness. These symptoms have been occurring with increasing severity for the past several weeks.
She presented with similar symptoms 3 months ago, at which time her drug regimen was changed from methotrexate
and NSAID therapy to her current regimen below.
PMH: RA × 6 years S/P, hysterectomy 4 years ago, HTN × 10 years
FH: Father died from complications after a traumatic fall at age 65. Mother died of a hip fracture and pneumonia at age
78. No siblings.
SH: Housewife; married for 32 years; has two grown children with no known medical problems. Denies alcohol or tobacco
use. Volunteers in the community extensively, but has been doing less in the past 2 months.

Transcribed Image Text:Meds: Hydrochlorothiazide 25 mg PO Q AM, Norvasc 10 mg PO once daily, Nabumetone 750 mg = 2 tabs po Q HS, Prednisone 5 mg = 1/2 tab po Q AM, Methotrexate 2.5 mg = 6 tabs po once a week, Hydroxychloroquine 200 mg = 1 tab po BID, Sulfasalazine EC 500 mg = 1 tab po BID, Folic acid 1 mg PO once daily. The patient receives medications at a local community pharmacy. The medication profile indicates that she refills her medications on time on the first of each month. All: Penicillin (rash 25 years ago) ROS: Swelling in the left knee; decreased ROM in hands; morning stiffness every day for about 3 hours; fatigue experienced daily during afternoon hours; denies HA, chest pain, SOB, bleeding episodes, or syncopal attacks; denies nausea, vomiting, diarrhea, loss of appetite or weight loss; reports minor visual changes corrected with stronger prescription glasses. Objective PHYSICAL EXAMINATION Gen: Pleasant, middle-aged white woman in moderate distress because of pain and swelling in left knee VS: BP 138/80, P 82, RR 14, T 37.1°C; Wt 65.3 kg, Ht 5'6" . . Skin: No rashes; normal turgor; no breakdown or ulcers HEENT: Atraumatic; moon facies; PERRLA; EOMI; AV nicking visible bilaterally; pale conjunctiva bilaterally; TMs intact; xerostomia . Neck/Lymph Nodes: Supple, no JVD or thyromegaly; no bruits; palpable lymph nodes Chest: CTA Breasts: Normal; no lumps CV: RRR; normal S1, S2; no MRG Abd: Soft, NT/ND; (+) BS Genit/Rect: Deferred LABORATORY EXAMINATION TABLE 96-1 Lab Values Na 135 mEq/L K4.1 mEq/L Cl101 mEq/L CO₂ 22 mEq/L BUN 12 mg/dL SCr 0.8 mg/dL Glu 103 mg/dL MS/Ext: Hands: mild RA changes; swelling of the 3rd, 4th, and 5th PIP joints bilaterally; pain in the 3rd and 4th MCP joints on left; boutonnière deformity of the 3rd and 4th digits bilaterally; ulnar deviation bilaterally, decreased grip strength, L > R (patient is left-handed) Wrists: decreased ROM Elbows: good ROM; slight permanent contracture on right; fixed nodule at pressure point Shoulders: decreased ROM (especially abduction) bilaterally Hips: decreased ROM on right; atrophy of quadriceps, L > R Knees: pain bilaterally; decreased ROM on left; effusion/edema on left Feet: no edema; full plantar flexion and dorsiflexion; 3+ pedal pulses Neuro: CN II-XII grossly intact; muscle strength 5/5 UE, 4/5 LE, DTRS 2/4 biceps and triceps, 1/4 patella Hgb 10.0 g/dl Hct 31% WBC 13.0 x 10/mm³ Plt 356 x 10³/mm³ Ca 9.1 mg/dl Urate 5.1 mg/dL TSH 0.74 mIU/L AST 15 IU/L ALT 12 IU/L Alk phos 56 IU/L T.bili 0.8 mg/dL Alb 4.2 g/dL HbsAg (-) Anti-HCV (-) CK <20 IU/L ANA negative Wes ESR 47 mm/h RF (+) 1:1,280 Anti-CCP (+) aPTT 31 sec INR 1.0 Fasting Lipid Profile: T. chol 219 mg/dL LDL 106 mg/dl HDL 50 mg/dL TG 150 mg/dl. UA: Normal Chest X-Ray: No fluid, masses, or infection; no cardiomegaly Hand X-Ray: Erosion of MCP and PIP joints bilaterally; measurable joint space narrowing from previous x-ray 6 months ago Synovial Fluid: From left knee; white cells 23.0 x 103 /mm³, turbid in appearance DEXA scan of hip/spine: T-score reported as -2

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