A 39-year-old woman returns for follow-up for her rheumatoid arthritis. She has positive rheumatoid factor, but no organ or systemic involvement. She has joint swelling and pain in her left hand, right elbow and right knee. Her pain is at an 8 on a 10-point scale. She states the pain is worse in the evening after completing her workday as a school bus driver. She is currently on methotrexate 25 mg weekly. Her condition is worsening. She had bronchitis six weeks before and still has a dry cough, but no fever or dyspnea. The patient denies nausea, rashes, chest pain, headaches or palpitations. She has no known allergies. She had a miscarriage three years ago. She recently returned from visiting relatives in Russia.
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Explore This IssueApril 2018
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Her mother was diagnosed with rheumatoid arthritis 20 years ago but has since passed away.
The patient’s weight is 150 lbs., blood pressure is 106/74, and her temperature is 98.2° F. Her skin has no lesions or rashes. Her lungs have slight wheezing, but no rales or rhonchi; she is coughing. Her heart has a regular rate and rhythm, with no murmurs or rubs. Her abdomen has normal bowel sounds and no masses or tenderness. On joint exam, her left wrist is warm to the touch, but has full range of motion. Her right elbow lacks 5° of full extension and does not flex completely; it is swollen and warm to the touch. Her right knee has crepitus, tenderness on full flexion, slight warmth and moderate synovitis. The knee lacks 5° of both full extension and full flexion. Her gait is unsteady, because she minimizes weight bearing on the right due to the pain in her right knee.
- Rheumatoid arthritis in multiple joints, with positive rheumatoid factor, but no organ or systemic involvement.
- Cough and wheezing with history of recent bronchitis.
Plan & Assessment
The patient has been on the maximum dose of oral methotrexate for six months with insufficient improvement in her symptoms. Because of her severe right knee pain and awkward gait, she is given a prescription for tramadol 50 mg (#30) to take one up to three times a day as needed for pain; side effects were discussed. Options were discussed with the patient concerning the benefits and possible side effects of starting infliximab infusions, and the patient decided to proceed. A chest X-ray will be obtained because of the patient’s persistent cough, history of recent foreign travel and small possibility of methotrexate-related lung toxicity. She is also urged to see her primary care physician if the cough does not resolve. A TB test is done during the appointment in preparation for starting infliximab infusions. The patient is given an appointment for two weeks from today to begin the infusions.