Rheumatoid arthritis
Remember that all Episodic/Focused SOAP notes have specific data included in every patient case.
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Rheumatoid arthritis (RA) is an autoimmune disease in which the body’s own immune system attacks the joints on both sides of the body including the hands, wrist and knees. Early stages of RA include:
Joint pain, tenderness, swelling or stiffness for 6 weeks or longer
Morning stiffness for 30 minutes or longer
More than one joint is affected
Small joints ( wrists, certain joints of the hands and feet) are affected
The same joints on both side of the body are affected
The history would include complaints of the above systems along with deformities of the affected areas depending on the severity. Rheumatoid nodules are commonly observed over the olecranon process or other extensor surfaces of the limbs and may be tender (Dunphy, Winland-Brown, Porter, & Thomas, 2015). The patient may present with a low grade fever. A thorough history of other systems is elicited because of the involvement of other extra-articular organ systems. Physical exam would include inspection and palpation of the joints on both sides of the body. Passive and active range of motion may be limited due to the swelling and tenderness to the affected area. The initial diagnostic test is the presence of Rheumatoid factor (RF) in the blood. This test alone is not diagnostic and specific test such as circulating anti-CCP autoantibodies. Other test include a ESR, CRP, CBC, platelet count and joint fluid analysis. Studies for a more progressive diagnosis include ANA and comprehensive autoantibody panel. Management of RA progresses from conservative interventions to aggressive symptom management. Initial management would include heat/cold applications, exercise, rest, OT/PT, assistive devices, splints, and weight loss. Subsequent management for a more progressive version of the disease include drug therapies such as NSAIDs, analgesics, corticosteroids and DMARDs.Patient education focuses on medication therapy and control of pain and inflammation. Both primary and secondary medication nonadherence may be affected by low levels of health literacy and patient education (Joplin, Zwan, Joshua, & Wong, 2015). Emotional, spiritual and social education is advised due to disability and pain.
References
Joplin, S., Zwan, R., Joshua, F., & Wong, P. (2015). Medication adherence in patients with rheumatoid
arthritis: the effect of patient education, health literacy, and musculoskeletal ultrasound. BioMed
Research International, 2015, 10.
Dunphy, L., Brown, J., Porter, B., & Thomas, D. (2015). Primary Care: The Art and Science of
Advanced Practice Nursing. Philadelphia: F.A. Davis Company.
