1. The LaMonica Family:
Joint Pain
Molly Bruce, RN, BSN, FNP-Student
NURO 752

2. Mrs. Sofia LaMonica is a 78-yr-female who presents
with c/o shoulder pain, hip pain, fatigue, and weakness
that began about one month ago. She was diagnosed
with mild iron deficiency anemia (improved with
treatment), depression, Vitamin D deficiency (corrected
on replacement), and fibromyalgia by her previous PCP.
She has not noted improvement in sxs on current
regimen of cyclobenzaprine 10 mg at bedtime and
duloxetine 60 mg daily. Her daughter is with her and
reports that her mother has difficulty dressing herself,
needs help to stand from a chair, and has difficulty lifting
her arms. She denies headaches or changes in vision
or hearing.

3. Social History
Moved from Sicily 7 years ago to live with her daughter
and her son-in-law. Her primary language is Italian and
she speaks little English. Never smoker. Occasional
glass of wine. Former elementary school teacher. Four
children, 3 of whom live in the US, one is deceased.
Widowed x 25 yrs, not sexually active since her
husband died.

4. Past Medical History: HTN controlled on meds x 6
years, OA for which she takes occasional ibuprofen.
Hysterectomy age 38, no HRT, DEXA 4 years ago
normal BMD.
Family Medical Hx: Adopted, knows no biologic family
hx. Oldest daughter died age 24 from Lupus Nephritis
complications. All other children are well.

5. Medications
• Duloxetine 60 mg daily
• Cyclobenzaprine 10 mg at bedtime
• Valsartan 160 mg daily
• HCTZ 25 mg each morning
• Calcium 600 mg twice daily
• Vitamin D 2000 mg daily
• Ibuprofen 400-600 mg up to three times daily PRN

6. Considerations
• What are some socio-cultural considerations that should
be implemented for this patient?
• Consider the patient’s religious beliefs, family structure,
ethnic value, and cultural identity.
• Would it be appropriate to use her daughter as a
translator?
• No!
• What are the legal implications for using her daughter as a
translator?
• Misinterpretation of information could lead to mistakes or
misdiagnosis.

7. ROS: Pertinent Findings
• General: positive for – fatigue, weakness
• Psychological: negative for anxiety,
depression, memory loss
• Ophthalmic: positive for dry eyes. Negative for
blurry vision, vision loss other than r/t age
• ENT: Positive for decreased hearing r/t age.
Negative for - earache, sore throat, hoarseness,
dysphagia, facial pain, and dry mouth, jaw
claudication
• Allergy and Immunology: negative for hx of
allergies or frequent infections
• Hematological and Lymphatic: negative for
excessive bruising, swollen or painful nodes
• Endocrine: negative for hx of diabetes, thyroid
problems
• Respiratory: negative, denies SOB, wheezing,
cough
• Cardiovascular: positive for peripheral edema
in the evenings, resolves by morning; negative
for Chest pain, palpitations
• Gastrointestinal: positive for occasional
indigestion; negative for reflux, black or bloody
stools
• Genitourinary: positive for hx of UTI, otherwise
negative
• Musculoskeletal: Positive for - Joint pain,
Stiffness and Morning stiffness; negative for
joint swelling or redness
• Neurological: negative for - headaches and
numbness/tingling; positive for occasional
vertigo
• Skin/Hair/Nails: Negative for rash, itch,
unusual lesions, dandruff, abnormal nails.

8. Joints

9. Physical Exam
• VS: BP 124/62 | Pulse 68 | Temp
97.9 °F (36.6 °C) (Oral) | Resp
16 | Ht 1.626 m (5' 4") | Wt
60.782 kg (134 lb) | BMI 23.00
kg/m2
• General: NAD
• HENT: TM Pearly Gray, no
enlarged or tender nodes, thyroid
normal, PERLA, EOM intact, no
nystagmus
• Mouth: MMM, no lesions noted,
good dentition, uvula midline,
pharynx without erythema or
exudate
• Skin/Nails: warm & dry w/out
rash, no increased warmth or
tenderness
• CV: RRR: Temporal pulse 2+,
equal with no masses or
tenderness; trace edema from
toes to mid calf, cap refill
bilateral great toes <3 secs,
Pedal & PT pulses 1+, Radial
pulse 2+
• Lungs: CTA throughout; Normal
respiratory effort & rate
• Sensation: intact to touch,
position
• Strength: 4/5 UE & LE bilateral,
unable to stand without
assistance
• Neuro: Neg Romberg, finger to
nose & rapid alternating
movements normal
• DIP: no swelling, normal motion,
Heberden’s nodes 2,3 bilaterally
• PIP: no swelling, tenderness;
minor Bouchard’s nodes
throughout
• MCP: no swelling or tenderness
• Grip: mildly decreased strength,
complete, equal
• Wrist: decreased motion, no
swelling or tenderness
• Elbow: normal motion, no
swelling or tenderness
• Shoulder: limited, painful
motion, 5/10 tenderness, no
swelling
• Hip: mildly decreased adduction
and abduction
• Knee: normal motion, no
swelling, mild crepitus
• Ankle: normal motion, no
redness or swelling
• Foot/Toes: + squeeze
• Tender points: Widespread,
18/18 positive 3-4/10
• Other: Normal gait

10. Osteoarthritis

11. Osteoarthritis
• Definition: A degenerative disorder of the joints, with a prevalence that
increases with age. Joints affected normally involve the knee, hip,
hands, cervical and lumbar spine. These patients may have stiffness
and joint pain WORSE with activity.
• Pharmacologic Treatment Options
• Hand OA: Topical capsaicin or topical NSAIDs, oral NSAIDs/COX-2
inhibitors, tramadol
• >75 years-old, use topical rather than oral NSAIDs.
• Knee OA: Acetaminophen, oral NSAIDs, topical NSAIDs, tramadol,
intraarticular corticosteroid injections
• Hip OA: Acetaminophen, oral NSAIDs, tramadol, intraarticular corticosteroid
injections
• Risk Factors
• Older age
• Sex (females>males)
• Obesity
• Occupation: repetitive movement of joints
(Hochberg et al, 2012)

12. Diagnostics
• What studies/labs should be ordered?
CBC, CMP, Vitamin D, Inflammatory Markers, UA

13. Lab Results: CBC

14. Lab Results: CMP

15. Question
• Were there any CMP or CBC values that were significant to
developing differentials?
WBC: 13.0 (H)
Hemoglobin: 11.1 (L)
Seg (neutrophils): 88.9% (H)
Lymphocytes: 9.1% (L)
Monocytes: 1.8% (L)
Absolute neutrophils: 11.6 (H)
Urea Nitrogen: 24 (H)
Glucose: 102 (H)
BUN/Creatinine: 21.6 (H)
• Look at inflammatory markers and urinalysis!

16. Additional Work-Up
• ESR (Sed Rate): 84 (H)
• CRP: <0.8
• CPK: 189 U/L
• Rheumatoid Factor <30.0 IU/ML
• Vitamin D : 46 (25-Hydroxy)
• Color, UA yellow
• Appearance, Urine clear
• Glucose, Ur neg
• Bilirubin Urine neg
• Ketones, Ua neg
• Specific Gravity, Urine 1.005
• Blood, Urine neg
• pH, Urine 5
• Protein Urine neg
• Urobilinogen, Ua 0.2
• Nitrite, Urine neg
• WBC Esterase/Urine neg

17. Labs in Inflammatory Disorders
Acute Phase Reactants: Blood proteins that are either increased or decreased
w/in hours of inflammatory response.
CBC w/ diff: blood counts
CMP: liver and kidney functions
ANA: Elevated in SLE, Sjogren’s syndrome, RA, mixed connective tissue
disease, scleroderma, polymyositis/dermatomyositis
Anti-extractable nuclear antigen (ENA): Highly specific for SLE, but only found
in around 25% of SLE patients. Also found in systemic sclerosis and mixed
connective tissue disease
Rheumatoid factor: Sensitive for detecting RA
Anti-cyclic citrullinated peptide antibody (CCP): A newer biomarker for RA. Do
this lab w/ RF for RA dx. CCP can also be found in psoriatic arthritis, lupus,
Sjogren’s syndrome, TB, and inflammatory myopathies.
(Castro & Gourley, 2010)

18. Differential Diagnosis
Mrs. LaMonica: 78 years-old w/ shoulder and hip pain,
fatigue, morning stiffness and weakness x 1 month in
addition to difficulty dressing herself, lifting her arms, and
standing up from a seated position. Elevated ESR.
• Polymyalgia Rheumatica
• Rheumatoid Arthritis
• Fibromyalgia
• Polymyositis
• Overuse bursitis/tendonitis

19. Polymyalgia Rheumatica (PMR): An inflammatory
rheumatologic disorder with manifestations of aching and
morning stiffness that could involve the neck, hips, shoulders,
and torso.

20. Polymyalgia Rheumatica
• Pathophysiology: The cause of PMR is not known, but
inflammation is thought to occur due to an autoimmune
reaction causing the immune system to attack the
synovium. The reason for this is unknown. Environmental
and genetic factors are thought to play a role.
• Risk Factors
• Older age
• Average age of onset is 70 years-old
• Sex
• Females are twice as likely to develop PMR
• Ethnicity
• Caucasian patients are more likely to develop PMR
(Saad, 2014)

21. Polymyalgia Rheumatica: ACR
Diagnostic Criteria
1: An age of 50 years-old+ at onset
2: Bilateral aching & morning stiffness that lasts 30 minutes
or more that persists for at least 1 month, and involves at
least 2/3 following areas: neck or torso, shoulders or
proximal regions of the arms, and hips or proximal aspects of
the thighs
3: ESR (Westergren) elevated to 40 mm/h or more
4: Normocytic, normochromic anemia in approximately 50%
of patients

22. Mrs. LaMonica: PMR
Symptoms/RFs
• Shoulder and hip pain
• Morning stiffness
• >50 years-old
• Female
• Difficulty standing from
seated position
• Elevated ESR
• Swelling in lower
extremities
• Depression
• Rapid onset of symptoms;
symptoms for one month
• Decreased ROM in wrists,
shoulders, hips

23. PMR: Treatment
• PO Steroid and Tapering Regimen
• Prednisone 15mg QD x 3 weeks
• Then 12.5 mg QD x 3 weeks
• Then 10 mg QD x 4-6 weeks
• Then reduce by 1 mg Q 4-8 weeks OR alternate day reductions (7.5
mg/10 mg alternate days)
• IM Methylprednisolone: Used in milder cases. May reduce risk of
steroid-induced complications.
• Initial dose of 120 mg Q 3-4 weeks
• Reduce by 20 mg Q 2-3 months
• Duration of Treatment: Normally, 1-3 years of treatment is needed.
Some require small doses beyond this. Stop steroids when
continued lack of inflammatory symptoms. If needing > 3 years of
treatment, may need to consider alternative dx.
• Additional Therapies: Bone protection needed with LT corticosteroid
therapy.
(Dasgupta, 2010)

24. PMR: Relapse
Relapse should be treated ONLY under specialist care.
• Relapse includes recurring symptoms of PMR or new
onset of GCA.
• Treating Relapse:
• Onset of GCA
• Follow usual treatment guidelines for GCA.
• Recurring PMR
• Increase prednisone to previous higher dose
• Administer a single dose of IM methylprednisolone 120 mg
• After 2 relapses, need to consider immunosuppressive
therapy.
(Dasgupta, 2010)

25. PMR and GCA can occur together. We need to assess Mrs.
LaMonica for this, before implementing her treatment plan!
Giant Cell Arteritis: A chronic systemic inflammatory
vasculitis of both medium and large arteries that occurs in
patients >50 years-old. It often affects superficial temporal
arteries, and occurs due to an autoimmune reaction.
• Risk Factors: Etiology and pathogenesis unknown.
• Diagnosis of PMR (15% w/ PMR will develop GCA)
• Age (>50)
• Sex (F>M)
(Dasgupta et al., 2010)

26. GCA
• Diagnostics
• Temporal Artery Biopsy
• Can be negative in some patients. If they have a typical clinical
picture of GCA and respond to steroids, should be regarded as
having GCA.
• Others: CBC, urea, electrolytes, LFTs, CRP, ESR
• Acute-phase response is characteristic: elevated ESR, CRP,
anemia, abnormal LFTs, thrombocytosis, raised alk phos
(Dasgupta et al., 2010)

28. American College of Rheumatology
Classification Criteria for Giant Cell
Arteritis
Criterion[∗] Definition
Age at disease onset ≥50 yr Development of symptoms or findings beginning at
age 50 or older
New headache New onset or new type of localized pain in the head
Temporal artery abnormality Temporal artery tenderness to palpation or
decreased pulsation, unrelated to arteriosclerosis of
cervical arteries
Elevated erythrocyte sedimentation rate (ESR) ESR ≥50 mm/hr by the Westergren method
Abnormal artery biopsy Biopsy specimen with artery showing vasculitis
characterized by a predominance of mononuclear
cell infiltration or granulomatous inflammation,
usually with multinucleated giant cells

29. Symptoms of Giant Cell
Arteritis
Symptom Frequency (%)
Headache 76
Weight loss 43
Fever 42
Fatigue 39
Any visual symptom 37
Anorexia 35
Jaw claudication 34
Polymyalgia rheumatica 34
Arthralgia 30
Unilateral visual loss 24
Bilateral visual loss 15
Vertigo 11
Diplopia 9

30. Mrs. LaMonica: GCA
Symptoms/RFs
• 15-20% of patients with PMR might also have Giant Cell Arteritis
(GCA).
• Positive findings:
• >50 years-old
• Elevated ESR
• Occasional vertigo
• Negative findings:
• No headache
• No tenderness to temporal artery or decreased pulsation
• No jaw claudication
Is it likely that Mrs. LaMonica could also have GCA?
If we had a strong suspicion for GCA, would a referral be urgent?

31. GCA: Treatment
If Mrs. LaMonica were to develop GCA it would require a
PROMPT REFERRAL!
• 1/5th of GCA cases result in irreversible blindness.
Preventable with prompt diagnosis and treatment.
• Glucocorticosteroids: Start while awaiting results from
temporal artery biopsy.
• Uncomplicated GCA (NO visual disturbance or jaw
claudication): 40-60 mg prednisone QD
• Complicated GCA (evolving visual loss): 500 mg- 1 g of IV
methylprednisolone for 3 days before PO
glucocorticosteroids
• Visual Loss: 60 mg prednisone QD to protect contralateral
eye
• May require 1-2 years of treatment (Dasgupta et al., 2010)

32. Plan
• Pharmacologic:
• Prednisone 15mg PO daily x 3 weeks, then 12.5mg PO daily x 3
weeks, then 10mg PO daily x 4-6 weeks, then reduce by 1mg Q
4-8weeks
• Continue calcium and vitamin D. Add a Bisphosphonate
(Alendronate 10mg PO daily).
• D/C Ibuprofen. Start topical capsaicin for OA, 0.025 to 0.075%
TID-QID, as needed. Acetaminophen 650-1000mg up to QID, as
needed (no more than 4000mg/day to avoid liver toxicity).
• D/C Cyclobenzaprine. Increased r/of serotonin syndrome w./
Cymbalta. Also, increased r/of drowsiness and fatigue.
• Nonpharmacologic: Limit ETOH, do not smoke cigarettes, weight-
bearing exercise (as tolerated)
• Education: Educate on prednisone therapy- can weaken immune
system, no live vaccines, take w/ food, side effects; Educate on
S/S of GCA and importance of seeking emergent care if these
develop. Do NOT abruptly stop taking steroids.
(Dasgupta et al., 2009)

33. Recommendations for
Glucocorticoid Treatment

34. Falls: Risk Factors
• Polypharmacy: 4+
medications
• Accident, environmental
hazard
• Confusion, cognitive
impairment
• Postural hypotension
• Medications:
corticosteroids,
sedatives, anxiolytic
drugs, antihypertensive
meds
Preventing Falls in the
Elderly
• Elimination of
environmental hazards
• Review and modify
medications
• Provide balance training
• Involve family
• Provide follow-up

35. PMR: Follow-up & Monitoring
• Follow-up schedule: 24-72 hours; weeks 1-3, 6; months 3,
6, 9, 12 in first year (+ extra visits if relapse of adverse
events)
• Clinical Monitoring: At each follow-up visit, assess for…
• Response to treatment and disease activity
• Disease complications (ex. GCA)
• Atypical features
• Side effects r/t steroid therapy
• Laboratory Monitoring
• CBC, ESR, CRP, urea, electrolytes, glucose

36. Follow-up
Mrs. LaMonica returns two days later. Her HPI, ROS, and PE
remain unchanged. You review the lab results with her and
her daughter and discuss the likely differentials with patient
as well as your plan of care.

37. Should we refer Mrs. LaMonica
to a specialist?
Consider referral if…
A) Presentation with atypical
features/features that are
unlikely in PMR:
1. <60 years-old
2. >2 months onset
3. No shoulder involvement
4. No inflammatory stiffness
5. Prominent systemic features,
night pain, wt loss, neuro signs
6. Symptoms of other rheumatic
disease
7. Normal or extremely high
acute-phase response
B) Dilemmas in treatment
including:
1. Unresponsive or incomplete
response to corticosteroids
2. Contraindications to
corticosteroid therapy
3. A need for corticosteroid
therapy that will be prolonged
(>2 years)
Patients with typical clinical
presentations, adequate
response to treatment, and no
adverse events can be managed
in a primary care setting.
(Dasgupta et al., 2009)

38. Osteoporosis
• Primary
• Postmenopausal: low estrogen
• Senile: occurs > 70 years-old
• Secondary: Caused by other etiologies
• Diseases
• Pharmacological therapy
• Lifestyle behaviors
• Imaging Recommendations
• BMD every two years, in the absence
of new risk factors.
• FRAX
• http://www.shef.ac.uk/FRAX/

39. Mrs. LaMonica’s FRAX Score

40. Health Maintenance
What health maintenance does Mrs. LaMonica need, being
that she is a 78 year-old female?
• Bone Mineral Density (every other year): Last done 4
years ago
• Colonoscopy (every 5-10 years after age 50)
• Mammogram (annually after age 40)
• Vaccinations: PNA (>65 years-old), Zostavax (>60 years-
old), Tetanus

43. Sarah LaMonica

44. History of Present
Illness
Sarah LaMonica is a 27-yr-old female who presents today with c/o
painful red and swollen fingers, elbows, and knees for the past 3
weeks. She states her joints began to hurt after she returned from a 2
week backpacking trip with her partner along the Appalachian Trail.
She denies injury but did have a tick bite. She c/o feeling fatigued
even though she states she is resting well at night. She has not been
able to do her usual daily workout or runs because of the stiffness
and pain. She states it takes her “all morning to loosen up” and then
she is still stiff, but not as bad. States this “has really messed my life
up”. She denies other health issues other than PTSD. Reports her
LMP was 1 week ago. Her grandmother, Sophia LaMonica is a
patient here, and was recently diagnosed with PMR. Sarah wonders
if she could have that too since she is so tired.

45. Social History
• Lives with her partner, Diane and 9 month old adopted daughter,
Abbie. She attended college for one year but dropped out and joined
the army. She had two tours in Iraq, one for 6 months followed by a
second tour for 12 months. Manages a food co-op and taking some
education classes.
• Denies smoking. Drinks 1-2 beers each weekend with her friends.
Denies recreational drugs. Sexually active in monogamous relationship
with partner of 5 years. States she has a good family relationship
which has helped her deal with her PTSD since leaving the military.
The food co-op does not provide health insurance and she cannot get
coverage under her partner’s policy.

46. Family History
• Mother: 49yo- HTN, OA
• Father: 56yo- HTN, COPD, former smoker
• Brother: 18yo- healthy
• Sister: 16yo- asthma
• Paternal Grandmother: deceased 78yo- COPD, CHF
• Paternal Grandfather: deceased 82yo- COPD, MI
• Maternal Grandmother: 76yo- HTN, OA, PMR
• Maternal Grandfather: deceased 53yo- MI, HTN, CVA
• Maternal Aunt: deceased r/t SLE nephritis

47. Past Medical History
• PTSD
• Anxiety
• Appendectomy, age 9
Current Medications
• No prescription medications
• Takes daily MVI, Benadryl at night for sleep
• Was on Zoloft and Xanax for anxiety but could not afford it

48. Review of Systems
• General: positive for – fatigue, negative
for weakness
• Psychological: positive anxiety,
depression related to PTSD
• Ophthalmic:. Negative for blurry vision,
vision loss, dry eyes
• ENT: Negative for - earache, sore throat,
hoarseness, dysphagia, facial pain, and
dry mouth
• Allergy and Immunology: negative for
hx of allergies or frequent infections
• Hematological and Lymphatic:
negative for excessive bruising, swollen
or painful nodes
• Endocrine: negative for hx of diabetes,
thyroid problems
• Respiratory: negative, denies SOB,
wheezing, cough
• Cardiovascular: negative for Chest pain,
palpitations, edema
• Gastrointestinal: negative for reflux,
black or bloody stools, indigestion
• Genitourinary: negative for hx of UTI,
menorrhagia, metrorrhagia
• Musculoskeletal: Positive for - Joint
pain, Stiffness and Morning stiffness,
joint swelling
• Neurological: negative for - headaches
and numbness/tingling
• Skin/Hair/Nails: Negative for rash, itch,
unusual lesions, abnormal nails.

49. Physical Exam
• General: healthy, NAD
• Skin/Nails: no rashes, ulcers;
nails normal
• Lymph: no adenopathy noted
• Scalp/Hair: no scaling, no
alopecia
• Eyes: non injected, PEERLA,
EOMS full
• Mouth: normal mucosa
moisture, no ulcers
• Neck: no masses, thyroid
normal
• CV: RRR, normal S1 & S2, no
murmurs or rubs
• Lungs: clear to auscultation
• Abd: non tender, no
organomegaly
• C-Spine: normal lateral
rotation, lateral bending,
flexion and extension
• T-Spine: normal flexion and
extension, no tenderness,
normal alignment
• L-S Spine: normal flexion and
extension, no tenderness,
normal alignment
• Reflexes: 2+ biceps, triceps,
brachioradialis, knee and
ankle
• Muscles: 5/5 for deltoids,
biceps, triceps, quadriceps,
hamstrings and hip flexors
• Sensation: normal to light
touch, vibration and position
• Shoulders: FROM, no
swelling
• Elbows: 1+ swelling R elbow;
trace L elbow
• Wrists: trace swelling &
tenderness bilateral wrists
• MCPs: 3+ tenderness
throughout with trace
swelling 1, 2 L, 1+ 1,2 R
• PIPs: 2+ swelling & tenderness
2-5 bilaterally
• DIPs: no swelling, no
tenderness
• HIPs: FROM, no swelling
• Knees: L FROM, Tenderness;
R 1 + tenderness, 1-2+
swelling, no redness, mildly
increased warmth
• Ankles: no tenderness or
swelling
• Feet/toes: no swelling or
tenderness
• Bursa: no tenderness or
swelling

50. Physical Exam
Swollen PIPs
5
4
3
2
1
No swollen DIPs
Swollen MCPs

52. Physical Exam
Swollen knee

53. Evaluation
• Differential Diagnosis
• Rheumatoid arthritis
• Lyme disease
• SLE
• Osteoarthritis
• Psoriatic arthritis

54. Labs and Diagnostics
• CBC w/ differential
• CMP
• Rheumatoid Factor
• Acute Phase Reactants: ESR, CRP
• Anticyclic citrullinated peptide (Anti-CCP) antibodies
• Imaging: Ms. LaMonica is uninsured. Would you obtain
an X-ray on this patient?

55. Lab Results: CBC

56. Lab Results: CMP

57. Lab Results

58. The 2010 ACR-EULAR Classification Criteria for RA
Score
A) Joint Involvement
1 large joint 0
2-10 large joints 1
1-3 small joints (w/ or w/o involvement of large joints) 2
4-10 small joints (w/ or w/o involvement of large joints) 3
>10 joints (at least 1 small joint) 5
B) Serology (at least 1 test result needed for
classification)
Negative RF and negative anti-CCP 0
Low-positive RF or low-positive anti-CCP 2
High-positive RF or high-positive anti-CCP 3
C) Acute-phase reactants (at least 1 needed for
class.)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D) Duration of symptoms
<6 weeks 0

59. Sarah LaMonica
Score
A) Joint Involvement
1 large joint 0
2-10 large joints 1
1-3 small joints (w/ or w/o involvement of large joints) 2
4-10 small joints (w/ or w/o involvement of large joints) 3
>10 joints (at least 1 small joint) 5
B) Serology (at least 1 test result needed for
classification)
Negative RF and negative anti-CCP 0
Low-positive RF or low-positive anti-CCP 2
High-positive RF or high-positive anti-CCP 3
C) Acute-phase reactants (at least 1 needed for
class.)
Normal CRP and normal ESR 0
Abnormal CRP or abnormal ESR 1
D) Duration of symptoms
<6 weeks 0

60. Rheumatoid Arthritis
• Definition: An inflammatory disease characterized by swelling,
pain, stiffness, and loss of function of joints. Commonly occurs
in wrist and fingers.
• Pathophysiology: Autoimmune. WBCs travel to synovium and
cause synovitis, resulting in warm, red, swollen, and painful
joints. With progression of disease, inflammation of the
synovium results in destruction of cartilage and bone in the joint.
Thought to be caused by environmental and genetic factors.
• Risk Factors:
• Sex: F>M
• Age: middle-age
• Family history
(U.S. National Library of Medicine, 2015)

61. Rheumatoid Arthritis
(ACR, 2012)

62. Clinical Practice Guidelines:
Treatment of Early RA
(Singh et al,
2012)

63. (Singh et al, 2012)

64. Pharmacological Interventions
for RA
There is NO cure for RA. The goal of treatment is to lessen
symptoms and slow progression of disease.
• Glucocorticoids: May be prescribed at initial presentation of RA
symptoms or for flares. Resolution of joint pain and inflammation
after steroid therapy can help further confirm susceptibility of
RA.
• NSAIDs: Improve mobility. Help with pain.
• DMARDs: Mainstay treatment; methotrexate,
hydroxychloroquine, sulfasalazine, leflunomide
• Biologic agents: abatacept, humira, anakinra, etanercept,
remicaide, rituxan, etc.; normally taken w/ methotrexate
(ACR, 2012)

65. Non-pharmacological
Interventions for RA
• Diet
• Low cholesterol (at risk for CAD)
• Fish oils, plant oils can improve pain and swelling of joints
• Occupational/physical therapy: Can help preserve joint function
• Splints: Reduce joint pain and improve function of joints
• Exercise
• Increase ROM: preserve/restore joint function
• Increase strength: isotonic, isometric, isokinetic
• Increase endurance: walking, cycling, swimming
• Surgery: End-stage RA; damaged joints
(National Guideline Clearinghouse, 2012)

66. Sarah LaMonica: Plan
• What medications will you prescribe, if any?
• Prednisone, taper as directed.
• What education will you provide the patient with?
• Take prednisone with food. Discuss side effects: emotional
lability, appetite changes, anxiety, insomnia, headache,
weight gain, etc.
• What are her options for obtaining health insurance?
• Medicaid: see if she meets qualifications
• Medically Indigent Adult Programs
• Veterans Benefits
(Forester, 2009)

67. Follow-up
Ms. LaMonica returns to the clinic in one week. Her joint
swelling has improved on prednisone and she generally is
feeling much better. She continues on prednisone taper.
PE: Unchanged other than she now has no swelling in her
joints.
What is your diagnosis, based on the findings?

68. Plan
• Prescriptions: NSAIDs, if still having joint pain. Continue
prednisone taper.
• Referrals: Rheumatology, first available appointment.
Send over copies of her office notes, labs, and current
medications.
• Patient Education: Educate patient on rheumatoid arthritis
and how it can be managed. Educate on importance of
seeing rheumatologist.
• Follow-up: After rheumatology consult, and as needed.

69. The Uninsured
Resources for PCP:
• GoodRx
• What You Can Do to Help Uninsured Patients:
http://www.aafp.org/fpm/2009/0900/p21.html
• Is the patient really uninsurable?
• Review OOP costs of labs/diagnostics with patients
• Prescribe generic medications
• Be aware of large retail companies offering more affordable
medication prices
• Offer discounts to cash-paying patients

70. PTSD
Sarah, returns several months later. She has been
diagnosed with RA. The diagnosis seems to have triggered
her nightmares, anxiety and insomnia. She is having a hard
time taking care of Abbie and had to quit her job. Things
were going so well. Now she needs your help. Can you give
her something for sleep? She just wants to be knocked out.

71. PTSD
• Definition: Occur in patients for >1 month after being exposed to
a traumatic event causing them significant distress or
impairment in occupational, social or other areas of functioning.
• Symptoms: avoidance of stimuli associated w/ traumatizing
event, re-experiencing of the traumatic event, numbing
sensation, increased arousal
• PTSD can appear alone, or more commonly w/ co-occurring
conditions (insomnia, identity problems, mood changes,
difficulties in interpersonal relationships, nightmares, chronic
pain) or with other psychiatric disorders (anxiety, depression,
substance abuse)
May have delayed onset (at least 6 months after the event).
(Department of Veterans Affairs, 2010)

72. PTSD: Screening
In primary care, the PTSD Screen is used:
In your life, have you ever had any experience that was so frightening, horrible, or
upsetting that, in the past month, you:
1. Have had nightmares about it or thought about it when you did not want to?
YES / NO
2. Tried hard not to think about it or went out of your way to avoid situations that
reminded you of it?
YES / NO
3. Were constantly on guard, watchful, or easily startled?
YES / NO
4. Felt numb or detached from others, activities, or your surroundings?
YES / NO
The results of this test are considered "positive" if a patient answers "yes" to any
three items.
(Department of Veterans Affairs, 2010)

73. PTSD: Treatment
• First-line treatment for PTSD based on guidelines suggest the
initiation of psychotherapeutic interventions using effective
modalities of trauma-focused therapy or stress management
AND/OR initiating pharmacotherapy (mono-therapy using SSRI or
SNRI)
• Adjunctive therapy might include treatment of symptom-specific
management including insomnia, pain, or anger.
• Ensure the patient has an adequate support system.
(Department of Veterans Affairs, 2010)

74. PTSD: Resources
• General and mental
health; Refer patient!
• Support groups
• VA Benefits Counselors
• PTSD Association
• Anxiety and Depression
Association of America
• National Alliance for
Mental Illness

75. References
• American College of Rheumatology. (2012). Rheumatoid arthritis. Retrieved from:
https://www.rheumatology.org/Practice/Clinical/Patients/Diseases_And_Conditions/Rheumatoid_Arthritis/
• American College of Rheumatology. (2010). Rheumatoid arthritis classification. Retrieved from:
https://www.rheumatology.org/practice/clinical/classification/ra/ra_2010.asp
• Castro, C. & Gourley, M. (2010). Diagnostic testing and interpretation of tests for autoimmunity. The Journal
of Allergy and Clinical Immunology, 125(2), 238-247.
• Clauw, D.J. (2014). Fibromyalgia: A clinical review. The Journal of the American Medical Association, 311(15),
1547-1555.
• Dasgupta, B., Borg, F., Hassan, N., Barraclough, K., Bourke, B., Fulcher, J.,… & Hollywood, J. (2009). BSR
and BHPR guidelines for the management of polymyalgia rheumatica. Oxford Journals, 109(10), 1-5.
• Dasguta, B. (2010). Concise guidance: Diagnosis and management of giant cell arteritis. Retrieved from:
https://www.rcplondon.ac.uk/sites/default/files/giant-cell-arteritis-concise-guideline.pdf
• Dasgupta, B., Borg. F., Hassan, N., Alexander, L., Barraclough, K., Bourke, B.,…Fulcher, J. (2010). BSR and
BHPR guidelines for the management of giant cell arteritis. Oxford Journals, 109(10).
• Department of Veterans Affairs. 2010. Clinical practice guidelines for management of post-traumatic stress.
Retrieved from: http://www.healthquality.va.gov/guidelines/MH/ptsd/cpg_PTSD-FULL-201011612.pdf
• Forester, R., & Heck, R. (2009). What you can do to help your uninsured patients. Family Practice
Management, 16(5), 21-24.
• Grossman, J., Gordon, R., Ranganath, V., Deal, C., Caplan, L., Chen, W.,… & Curtis, J. (2010). American
College of Rheumatology recommendations for the prevention and treatment of glucocorticoid-induced
osteoporosis.

76. References Cont’d
• Hochberg, M., Altman, R., April, K., Benkhalti, M., Guyatt, G., McGowan, J.,… & Towheed, T. (2012). Recommendations for the use of
nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care and Research, 64(4), 465-474.
• National Clinical Guideline Centre. (2014). Osteoarthritis: Care and management in adults. Retrieved from:
http://www.guideline.gov/content.aspx?f=rss&id=47862#Section420
• National Guideline Clearinghousee. Rheumatoid arthritis: Diagnosis, management and monitoring. Retrieved from:
http://www.guideline.gov/content.aspx?id=39244
• National Institute of Arthritis and Musculoskeletal and Skin Diseases. (2012). Polymyalgia rheumatica and giant cell arteritis. Retrieved from:
http://www.niams.nih.gov/health_info/polymyalgia/
• National Osteoporosis Foundation. (2014). Clinician’s guide to prevention and treatment of osteoporosis. Retrieved from:
http://nof.org/files/nof/public/content/file/2791/upload/919.pdf
• Saad, E.R. (2014). Polymyalgia rheumatica. Retried from: http://emedicine.medscape.com/article/330815-overview#a4
• Sinusas, K. (2012). Osteoarthritis: Diagnosis and treatment. American Family Physician, 85(1), 49-56.
• United States National Library of Medicine. (2015). Rheumatoid arthritis. Retrieved from:
http://www.nlm.nih.gov/medlineplus/rheumatoidarthritis.html
• University of Maryland Medical Center. (2013). Osteoporosis. Retrieved from: http://umm.edu/health/medical/reports/articles/osteoporosis
• Veterans Health Initiative. (2002). Post-traumatic stress disorder: Implications for primary care. Retrieved from:
http://www.publichealth.va.gov/docs/vhi/posttraumatic.pdf