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At the outpatient clinic Mrs Louise Sorrentino-Martorelli, born 10-4-1970 was seen for a second opinion regarding treatment of Rheumatoid Arthritis at the 28th of November.



Previous history:

M Hashimoto since 1987

March 2008: Symmetrical pain in hands and feet. Morning stiffnes 1 hour and disability

Analysis, Rheumatoid Factor positive, CCP-positive and raised CRP
Radiology: periarticular osteoporosis

September 2008: Methotrexate 15 mg, Folic Acid 5 mg, prednisone 12 mg

Since the 20th November 2008: 8 mg prednisone.



Actual history:

The complains compatible with arthritis are almost gone since the prednisone therapy. There is no skincomplaints, no complaints compatible with Sjogren’s disease.

The side effects of prednisone are gain of weight and a buffalo humo.

Current weight is 115 kg with a length of 1.60 meter.



Tractus history: no specific complaints

Patients doesnot smoke and drinks no alcohol.



Medication:

Thyrax 175/150 with a TSH of 6.8

MTX 15 mg

FZ 5 mg



Family history: mother has Rheumatoid Factor in her blood



Physical Examination:

Cushingoid, 160 cm, 115 kg,.

Diffuse pain sensations on the skin



Rheumatological examination:

Left jaw joint painful

Both wrists slightly swollen

To little strength of the fists

Bilateral pressure pain in the forefeet

No sign of limited spinal motility.



Discussion and advice:

- The patient had a diagnosis of RA based on the clinical picture, the autoantibodies and the X-ray.

The advice is achieve anti-rheumatic treatment by either combination therapy with DMARDS (sulphasalazine, Methotrexate and hydroxychloroquine) or a combination of methotrexate and a TNF-blocking agent. At the same time we felt that she has more disadvantage from the corticosteroid medication than advantages. The advice is to stop the prednisone treatment in a period of 8 weeks.

- The non-pharmacological treatment of RA can be intensified by starting physical therapy as well getting weight reduction by sporting 3 times a week. This will also be beneficial in the management of pain.

- Finally we felt that the TSH was slightly elevated and the patient may benefit from a slight increase in the thyroid medication to thyrax 175ug per day.



Best wishes

prof dr TWJ Huizinga
Chairman department of rheumatology, C1-41
Leiden University Medical Center
Albinusdreef 2
PO Box 9600
2300RC Leiden
The Netherlands
phone-31-71-5263598
fax -31-71-5266752