Running head: RHEUMATOLOGY CASE 1 Rheumatology case Course name Student’s name Professor’s name University affiliation Date RHEUMATOLOGY CASE 2 Rheumatology Case Patient background information The patient that has been highlighted in this case is a 55-year-old married female. She presents to the primary care office with a history of 6 weeks of joint pain. She states that the pain starts from her lower back then moves to the knees, hips, wrists, fingers, and toes. Some of re medications she has been taking to relieve her symptoms are Motrin, Tylenol, and Aleve but does not take prescribed medications. She also lacks sleep at night but has no medical history. She also has no allergies to medications. Subjective Data • Joint pain: The patient has been having joint pain for the past 6 weeks. Kim Lee described that her pain started from her lower back and progressed to her knees, hips, wrists, and now fingers and toes. This indicates that the disease has progressed as the symptoms have progressed to other parts of the body. The patient will be asked if she feels pain when she stretches and at what range of motion does the pain occur mostly. • Fatigue: Kim also states having constant fatigue. Reflexes will be tested to see if the patient is weak and checking of muscle strength. • Loss of appetite: The patient will also be asked to mention she has experienced any loss of appetite which is common in Rheumatology. • Joint stiffness, symmetrical: The paint admits that there has been some stiffness in her hands for the past 6 weeks. She will be asked if joint stiffness occurs in the morning. She cannot sleep at night due to inactivity. Physical exam RHEUMATOLOGY CASE A thorough physical examination is essential, as many multifaceted rheumatological disorders are multi-systematic. The patient must be dressed in an examination gown. The musculoskeletal exam, as done by subspecialists or carried out as a separate unit, can be integrated into the general examination. However, due to the associated pain and difficulty the patient's movement should be kept to a minimum. Swelling and redness: This is one of the objective data that will be important in assessing the patient for the disease. Rheumatology usually destroys the immune system. There is some swelling in her hands especially the joints. She has been using some medications like Motrin, Tylenol, and Aleve to lessen the symptoms. Warmth and tenderness of the joints: This data can be obtained by touching the affected joints. In musculoskeletal tests, the convention is "STL" which stands for S = swelling, T =tenderness, and L = limitation. The grading for swelling will be from 0-3 where 0 represents none, 1 for mild, 2 for moderate while 3 is marked. Swelling can reflect synovial (pannus) or fluid proliferation (Doherty, 1992). The evident swelling will indicate signs of a bony enlargement as well as the thickening of overlying structures or the atrophy of surrounding tissues (skin / subcutaneous fat). (Except for elderly skin/muscles) Also tenderness will be graded from 0-3 where 0= none, 1 shows that the joints are tender, 2 indicates that they are tender and winces while 3 means that they are tender, winces, and withdraws. The pressure on the patients swelled will show whitening on the thumbnail. During the tenderness assessment, there should be no lateral movement on the thumb(Lawry, 2012). Tenderness is developed by motion instead of direct palpation of deep joints like the shoulders and hips. The limitation of Movement will also be graded from a range of 0-5, in which 0 will represent a full range of motion [ROM], 1 will 3 RHEUMATOLOGY CASE 4 indicate a loss of motion by 0-9% loss of ROM, 2 shows a loss of ROM by 10-19%, 3 indicates a 20-49% loss of ROM, 4 shows a loss of ROM by 50-99% while 5 will represent ankylosis. Hand ROM can be assessed by quickly recording the percentage fist formation and grip strength recorded as good/fair/poor. For occupational therapy (OT) a detailed hand assessment can be requested. This overview of the musculoskeletal exam is also a basis for a proper general evaluation. It is possible in 15 or fewer minutes. However, more precise diagnostic testing is needed based on the initial findings and a more reliable measurement of the full range of movement will be required (Fam et al., 2010). These skills can only be gained through practice and knowing when to apply them. To prove a full physical examination was conducted and to understand the exact findings, a complete description of the MS exam is essential (Malanga & Nadler, 2006). The billing code will also be impacted. In terms of joints swelling, range of motion, tenderness, and function, every area evaluated must be addressed. Differential diagnoses for polyarticular pain 1.Rheumatoid Arthritis (RA) 2. The systemic lupus erythematosus (SLE) 3. Psoriatic arthritis 4. Ankylosing Spondylitis (1) Rheumatoid Arthritis (RA) It is a progressive autoimmune disorder that initially causes signs and symptoms, such as joint pain and the swelling of the hands and the feet (Goodman & Fuller, 2011). Chronic inflammation of the RA can permanently damage and cause the deformation of the joint. RA is RHEUMATOLOGY CASE 5 associated with the onset of disease flares and disease progression. Rheumatoid arthritis (RA) affects various people in various ways. It may be mild, moderate, or severe, and individual symptoms vary. For RA development there is no exact timeline. Otherwise, the disorder becomes compounded over time and progresses through specific stages without effective treatment. Many new therapies have succeeded in slowing or even blocking the progression of RA. More energy will be spent on treating the conditions effectively and on looking after the patient's health if the care delays the progression of RA. Multiple joints in rheumatoid arthritis are typically (polyarthritis) affected in a symmetrical pattern, but not always (Goodman & Fuller, 2011). Joint damage can occur early and is not always related to the severity of RA symptoms. The 'rheumatoid factor' is an antimicrobial antibody that 80% of rheumatoid arthritis sufferers in the blood. A simple blood test detects the rheumatoid factor. Possible risk factors for rheumatoid are genetic history, smoking, inhalation of silica, and bowel microbes (good bacteria). There is no cure for RA. The optimal treatment of rheumatoid arthritis includes patient education, rest and exercise, joint protection, medicines, and sometimes surgery. (2) The systemic lupus erythematosus (SLE) The systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by nuclear and cytoplasmic antigens anti structures, multi-system inflammation, clinical protein manifestations, and relapse and remissions More than 90 % of cases of SLE occur in women, often from childhood. See the following picture. The immune system usually combats hazardous infections and bacteria to maintain a healthy body (Lahita, 2004). When the immune system attacks the body, the autoimmune disease occurs because something strange is confusing it. Many autoimmune disorders, including systemic erythematous lupus (SLE), occur. RHEUMATOLOGY CASE 6 A proportion of immune conditions with similar physiological presentations as well as laboratory aspects have been identified with the name Lupus, however, SLE is perhaps the most normally utilized kind of lupus. SLE is a chronic illness that can have deteriorating symptoms alternating with mild symptom periods. Most SLE people can live with treatment a normal life. Systematic photosensitive rash (SLE) occurs typically on the faces or limbs of areas exposed to the sun. The meta-carpophalanges (MCP) and proximal interphalangeal (PIP), interphalangeal, and distal interphalangeal joints (DIP), are spared even though interphalangeal are affected(Lahita, 2004). The basis believes that the number of persons with the condition is considerably higher and is not diagnosed in many cases. Symptoms may vary with time and may change. Common signs include joint pain, severe fatigue, headaches, joint swelling, anemia, hair loss, blood clotting, and fingers turning white (Lahita, 2004). Lupus symptoms are also the symptoms that make diagnosis difficult for many other diseases. (3) Psoriatic arthritis Psoriatic arthritis is a type of arthritis that has psoriasis in some people — a condition that has red, silvery-shaped skin patches. The majority of people are first diagnosed with psoriatic arthritis and are then treated with it, but joint pains will sometimes be seen before patches occur. Its major signs and symptoms are joint pain, swelling, and stiffness. Individuals can be affected mildly severely by this disorder on any part of their body which may include the spine and fingertips. Disease flares can alternate with remission times in both psoriasis and psoriatic arthritis. There is no treatment for psoriatic arthritis but the symptoms can be relieved and joints damage is prevented. Psoriatic arthritis can cause a disability if treatment is not administered. 4. Ankylosing Spondylitis RHEUMATOLOGY CASE 7 Ankylosing Spondylitis is a disorder that causes inflammation and the fusion of smaller spine bones over time. This merge reduces the flexibility of the back and can lead to a stiff forward stance. Ribs may even make it harder to breathe deeply when they are fused. Ankylosing spondylitis is more common among men than females. In early adulthood, signs, and symptoms usually start. The treatment for ankylosing spondylitis has not been established; even so remedies may significantly reduce one’s symptoms leading to a slow progression of the disease. Inflammation could also emerge in many other parts of the body. In the lower back and hips, pain and steepness could include early signs of ankylosed spondylitis in most cases in the morning and even after periods of rest. Tiredness and neck pain are also regular. With time, irregular symptoms may get worse, start improving, or slow down. Differential diagnoses for myalgia 1.Polymyalgia rheumatica 2.Sarcoidosis 3. Rhabdomyolysis 4.Spinal stenosis 1. Polymyalgia rheumatica Polymyalgia rheumatica (PMR) is a chronic inflammatory condition affecting elderly people (Dasgupta & Dejaco, 2016). It is also more common in women than in men and more often than other races in the Caucasians. It usually develops up to 70 years old and is rarely seen in people under 50 years of age. PMR may last between one and five years, but it does vary from person to person. Around 15 % of people with PMR experience a potentially dangerous disorder known as giant cell arteritis (Masiero & Carraro, 2018). The proximal myalgia of the hip and shoulders is one characteristic of the condition and is commonly accompanied by stiffness of RHEUMATOLOGY CASE 8 more than 1 hour in the morning. The association between GCA and PMR is not yet clearly established despite parallels between age at the beginning and certain clinical manifestations. PMR (presentation and work) is a clinical diagnosis based upon the complexity of symptoms and the exclusion of other possible diseases. Corticosteroids are considered as the treatment of choice and are considered pathognomonic in rapid reaction to low-dose corticosteroids. 2. Sarcoidosis It is a disorder caused by a type of inflammatory cells (granulomas) that develops in any part of the body especially the lymph nodes and lungs. It can also affect the skin, eyes, heart among other organs (Masiero & Carraro, 2018). There is no cure for Sarcoidosis but most people do very well without or with minimal therapy. Sarcoidosis goes away in some cases by itself. Sarcoidosis can also last for years and can destroy the liver. The sarcoidosis signs and symptoms vary according to which body parts are severely impacted. Sometimes sarcoidosis usually develops steadily and causes long-lasting symptoms. Sometimes, signs quickly arise and then they rapidly vanish. Many individuals with sarcoidosis show no signs and symptoms, and the disease can be found only for a different reason when the chest X-ray is done. 3. Rhabdomyolysis The disintegration of weak skeletal muscle is rhabdomyolysis. Rhabdomyolysis causes direct or indirect muscle tears as a serious syndrome. The death and release of muscle fibers into the bloodstream is an outcome (Doherty, 1992). This can lead to grave complications like a renal failure (kidney). In other words, waste and urine cannot be removed from the kidneys. Rhabdomyolysis can also lead to death in rare cases. Early diagnosis, however, also yields a positive outcome. Muscle collapse causes the bloodstream to release myoglobin. Myoglobin is RHEUMATOLOGY CASE 9 the protein in the muscles that retain oxygen. It may cause kidney damage if you have too much myoglobin in your blood. In the United States, approximately 26,000 rhabdomyolysis cases are registered per year. Most of the patients with rhabdomyolysis are commonly diagnosed with intravenous (IV) drying fluids from the veins. In certain cases, dialysis or hemofiltration may be required to treat kidney damage. 4.Spinal stenosis Stenosis in the spinal tubes is caused by the narrowing of one or more openings (foramines) within the spine and tends to compress the backbone gradually (Doherty, 1992). No symptoms may arise if the narrowing is small. Increased narrowing of the spine will compress the nerves and cause problems. This may occur in the vertebral canal and/or in the intervertebral foramina where spinal nerves exit the spinal canal. This phase is not required for spinal canal use. The spinal nerve or spinal cord can get compressed and cause pain, tingling, and/or weakness, depending on the position and how much narrowing occurs over time. The spine is a column of bones called vertebras which provide the upper body with stability and support. It makes it possible for us to twist (Doherty, 1992). Spinal nerves pass through vertebral openings and convey signals from the brain to the body. Such nerves are covered by the bone and tissue around them. This may affect functions such as walking, balance, and feel if they are weakened or degraded in some way. Spinal stenosis is a disease that narrows the spine and tends to compress the backbone gradually. No symptoms may arise if the narrowing is small. An unnecessary reduction will compress the nerves and cause problems. Diagnostic tests 1. Blood test RHEUMATOLOGY CASE 10 A blood test will be done to check for the levels of erythrocyte sedimentation (ESR or sedimentation rate) or C-reactive protein (CRP). This is because the condition involves an inflammatory process in the body where erythrocyte is released. (Masiero & Carraro, 2018). The Rheumatoid factor as well as anti-cyclic citrulic peptide (anti-CCP) antibodies are also investigated in other common blood examinations. One limitation with blood tests like Erythrocyte Sedimentation Rate (ESR) is that it can be cumbersome to perform. 2. Imaging testing X-rays will be done to monitor the joints as the disorder progresses. Other imaging tests can include ultrasound tests and MRI tests to assess the seriousness of the disease(Masiero & Carraro, 2018). The limitation of the tests is that there is a high degree of dependence on the operator which may affect the quality of images. RHEUMATOLOGY CASE 11 References Doherty, J. (1992). Critical examination in rheumatology. London: Wolfe. Fam, A. G., Lawry, G. V., & Fam, A. G. (2010). Fam's musculoskeletal examination and joint injection techniques. Philadelphia: Mosby. Goodman, C. C., & Fuller, K. S. (2011). Pathology for the Physical Therapist Assistant - EBook. Saunders. Lahita, R. G. (2004). Systemic lupus erythematosus. San Diego, Calif.; London: Academic Press. Lawry, G. V. (2012). Systematic musculoskeletal examinations. New York, N.Y: McGraw-Hill Education LLC. Malanga, G. A., & Nadler, S. (2006). Musculoskeletal physical examination: An evidence-based approach. Philadelphia, PA: Elsevier Mosby. Masiero, S., & Carraro, U. (2018). Rehabilitation medicine for elderly patients. Cham, Switzerland: Springer. 4/29/2020 Welcome to 665 Didactic Summer 2020 1 Rheumatoid Topics  Rheumatoid Arthritis  Arthralgias  Lyme Disease  Psoriatic Arthritis  Fibromyalgia  Ankylosis Spondylitis  Gout  Polymyalgia rheumatica  Systemic Lupus (SLE)  Myositis  Hashimoto’s Thyroiditis   Osteoarthritis Swan Neck vs Boutonniere deformities  Osteoporosis  Herbeden’s nodes 2 Rheumatoid Topics  Rheumatoid Arthritis  Arthralgias  Lyme Disease  Psoriatic Arthritis  Fibromyalgia  Ankylosis Spondylitis  Gout  Polymyalgia rheumatica  Systemic Lupus (SLE)  Myositis  Hashimoto’s Thyroiditis   Osteoarthritis Swan Neck vs Boutonniere deformities  Osteoporosis  Heberden's nodes 3 1 4/29/2020 Rheumatoid Labs 4 Rheumatoid vs Osteo 5 6 2 4/29/2020 Swan-neck vs Boutonniere 7 Lyme 8 Lyme Disease 9 3 4/29/2020 RMSF 10 Gout 11 Gout 12 4 4/29/2020 SLE 13 5
Purchase answer to see full attachment