Diagnoses:
- Rheumatoid Arthritis
- Raynaud's Phenomenon
Current Rheumatology Medication:
1. Methotrexate 15mg weekly
2. Hydroxychloroquine 200mg twice daily
Allergies:
- Penicillin
Previous DMARDs:
- Sulfasalazine (stopped due to side effects)
Investigations:
1. Rheumatoid factor: Elevated
2. Anti-CCP antibodies: Positive
3. ESR: 45 mm/hr
4. CRP: 25 mg/L
Disease activity score:
For Rheumatoid Arthritis, list:
- Tender joint count: 6
- Swollen joint count: 4
- Patient visual analogue score: 60mm
- CRP: 25 mg/L
- Duration of early morning stiffness: 60 minutes
Activity of Daily Living:
- Difficulty with buttoning clothes due to hand swelling.
- Problems with walking long distances due to knee pain.
Discussion:
The patient, [insert age] years old, presented today with a flare-up of their rheumatoid arthritis. They report increased joint pain and stiffness, particularly in the morning. The patient also reports ongoing symptoms of Raynaud's phenomenon, with episodes of finger discolouration in cold weather. The patient reports they have been experiencing increased fatigue. The patient's current medications were reviewed, and the patient reports they are tolerating them well. The patient's disease activity score was calculated, and the results indicate moderate disease activity. The patient was educated on the importance of medication adherence and lifestyle modifications. The patient was also advised on non-pharmacological management of Raynaud's phenomenon.
Key points:
- Increased joint pain and stiffness.
- Moderate disease activity.
- Ongoing Raynaud's symptoms.
Impression:
- Rheumatoid arthritis flare-up with moderate disease activity.
- Stable Raynaud's phenomenon.
GP Actions:
1. GP to please add folic acid 5mg once weekly to repeat prescription.
2. GP to please add hydroxychloroquine to repeat prescription — there are no monitoring requirements and no shared care agreement necessary.
Plan:
- Continue current medications.
- Review in 3 months.
- Discussed non-pharmacological management of Raynaud's phenomenon.
Raynaud’s management:
Non-pharmacological management:
- Avoiding inciting environmental factors, such as direct contact with frozen foods or cold drinks.
- Insulation against cold and local warming, including gloves, heavy socks, and hat particularly in winter.
- Avoiding smoking.
Pharmacological options:
- Calcium channel blockers are the class of drugs most widely used for treatment of Raynaud syndrome (e.g. nifedipine, nicardipine). The usual dosage of Nifedipine is 30–60 mg of the extended-release formulation taken once daily. Start with the lowest dose and titrate up as tolerated. If adverse effects occur, decrease the dosage or use another agent such as amlodipine or diltiazem.
- Other medications that may be of help include:
- Topical nitroglycerin (1% or 2%) may be helpful; however, some patients develop headaches and flushing which limits its use.
- Selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine or sertraline.
- Losartan.
