A 55-Year-Old Woman With Rheumatoid Arthritis

Abstract

DR PARKER: Mrs J is a 55-year-old woman with moderately severe rheumatoid arthritis (RA) that was diagnosed in 1985 after several years of intermittently swollen and painful joints. Due to her illness, she retired from her profession as a restaurateur. She still experiences daily pain in her joints and is facing surgery on her feet. She is married, lives in the Boston suburbs, and has managed care insurance.Mrs J first noted pain and swelling in her wrists and knees. Later, she experienced morning stiffness, pain, and disfigurement of her hands and feet. After years of symptoms, she was referred to a rheumatologist who made the diagnosis of RA. She did not have adequate clinical responses to oral or intramuscular gold, methotrexate, penicillamine, hydroxychloroquine sulfate, or cyclosporine, mostly because of adverse effects. She took minocycline for 3 months, allowing her to taper her prednisone dosage, but developed yeast infections. Mrs J's arthritis responds "magically" to prednisone, but she dislikes the adverse effects, including cushingoid appearance, weight gain, and diabetes. She describes feeling "run-down" when she tries to taper the prednisone regimen.Mrs J reports significant progress with her joint symptoms with exercise, especially in the water. She also uses mechanical tools to help with daily tasks such as opening jars. Despite her illness, she has remained very active with her family and in the local community. She finds chiropractic treatments quite useful.Her medical history is notable for insulin-dependent diabetes mellitus, Sjö gren syndrome, and gastritis. Her sister and mother have arthritis. She has 2 sons in good health.Her current medications include leflunomide (Arava; Hoechst Marion Roussel, Kansas City, Mo), 20 mg/d; prednisone, 10 mg in the morning and 5 mg at night; vitamin D, 50 000 U twice weekly; trazodone, 50 mg at bedtime; calcium, 1000 mg/d; folic acid, 1 mg/d; troglitazone (Rezulin; Parke-Davis, Morris Plains, NJ), 400 mg/d; and insulin.Abnormal findings on physical examination included her slightly cushingoid appearance with synovitis with warmth and soft tissue swelling in her wrists and metacarpophalangeal joints. She has ulnar deviation and swan neck deformities in her hands, a left knee effusion, and soft tissue swelling in both ankles. Her most recent laboratory test results include an erythrocyte sedimentation rate of 40 mm/h and rheumatoid factor of 183 IU/mL. MRS J: HER UNDERSTANDING AND PERCEPTIONS

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