Question

Use this case for questions 1 to 3. Bill is a 62 yo male with a 3 year history of fatigue, joint pain, and prolonged morning stiffness due to RA. He sees his family doctor in Fargo who has treated him with ibuprofen 200 mg four times daily and prednisone 5 mg daily for the past 12 months. However, worsening arthritis symptoms as well as stomach pain have made him seek a second opinion. A physical exam today revealed red, tender and swollen joints over the knuckles and proximal interphalangeal joints of each hand and over the wrists and toes. There are subcutaneous nodules near each elbow. He is 5'9" and weighs 180 lbs. Joint x-rays indicate joint erosion at the MCP and PIP joints. ESR is 69 (normal <30). Other lab tests are normal except hemoglobin is 9.9, hematocrit is 31 and BP is 145/94. Rheumatoid Factor is negative. Disease activity index (DAS28) = 6.97 (severe). Endoscopy reveals a large gastric ulcer. Diagnosis is confirmed as RA, with normocytic anemia and PUD.

1.         Write out an initial pharmaceutical care plan for the patient for ALL medical and pharmaceutical problems that require treatment in the following example format. Include in your plan all recommendations you have to manage his conditions, and how you can monitor disease activity.

Findings (subjective & objective)	Therapeutic Goals	Assessment	Plan and Monitoring	Patient Education
serum K = 3.1 Patient feels week	Normalize K (3.5 to 5.0 mEq/L) Relief of weakness	symptomatic hypokalemia	Give KCl 20 mEq po x 3 today, then 20 mEq daily Monitor serum potassium daily x 2 days, then monthly	Explain nausea may occur

2.         A friend has told Jack that if his rheumatoid factor blood test is negative, he does not have RA. Is this true?

3.         After he has tried your recommended treatment for 3 months, it has not worked well and Jack now has a severe flare of RA symptoms. In addition, he has just been diagnosed with type II diabetes as well. What drug treatment(s) for RA would you recommend now? Why? List your key monitoring parameters for the new treatment.

4.         Mary has been taking methotrexate for about 4 months (along with naproxen as needed). She is currently taking 15mg weekly but her RA is not under control yet and she been feeling really rough the past few days with a sore throat and a cough developing. It’s the weekend and she can’t reach her rheumatologist so she stops at your pharmacy. Should she stop taking MTX?

Answer 1

1. Nursing care plan

Findings - patient has fever , fatigue and his WBCs are raised

Therapeutic goals is to prevent infection and to treat it fast if infection has occurred .

Assessment - on assessing the patient has fever ,fatigue and increased white blood cells in the investigation .

Plan and monitoring - To give intravenous antibiotics and use aseptic technique while providing care to the patient and to decrease the dose of corticosteroid and monitor the response to antibiotics .

Patient education - providing health education to the patient about the side effects of the medicines ,about compliance ,how to maintain hygiene including hand washing ,clean environment to avoid infection .

2.No it is not true , patients who test negative for rheumatoid factor but still exhibit symptoms and meet other diagnostic criteria may still be diagnosed with rheumatoid arthritis.

3. Hydroxychloroquine is used for the patients with arthritis to decrease the risk of developing diabetes and Abatacept is used when other drugs don't work to prevent diabetes associated with rheumatoid arthritis. Here its diabetes mellitus type 2 , patient will be advised to do modification in his diet , lifestyle etc to prevent diabetes and then if does not work then oral medications will be started .