HS2264: A 25-year-old male patient was admitted to the emergency department with a 3-day history of fever, body aches: Pathophysiology and Pharmacology 2 Assignment, NYP, Singapore

Case study (1)

A 25-year-old male patient was admitted to the emergency department with a 3-day history of fever, body aches, and a progressively worsening headache. There was a recent travel history to Kenya in Sub-Saharan Africa.

On the day of admission, he developed a stiff neck, vomited, and complained the light hurts his eyes. On examination, the temperature was 41◦ C, pulse rate was 135 beats per minute, and blood pressure was 90/60 mmHg. Neurological examination showed that he was drowsy and unaware of his surroundings, his headache became worsens on passive flexion of the neck, and was unable to touch his chin to his chest. Examination of the skin showed petechial rashes on the lower extremities.

Based on the history and clinical examination, the most likely diagnosis for this
the patient was meningococcal meningitis.

Questions

1. With reference to the epidemiology of meningococcal meningitis, what is a meningitis belt? How can cases of meningitis be prevented in the meningitis belt?
2. Describe the complications of meningococcal meningitis.
3. Discuss whether a lumbar puncture for the diagnosis of meningitis should or should not be performed in this patient.
4. What is the treatment plan for this patient and his close family contacts?

Case study (2)

A 37- year- old woman gradually developed painful wrists and early morning
stiffness over three months. On examination, both wrists and the metacarpophalangeal joints of both hands were swollen and tender but not
deformed. There were no nodules or vasculitic lesions. On investigation, she was found to have a raised C- reactive protein (CRP) level but normal hemoglobin and white cell count. A rheumatoid factor test was negative and antinuclear antibodies were not detected. The clinical diagnosis was made as early rheumatoid arthritis, and her doctor prescribed ibuprofen to the patient.

Despite some initial symptomatic improvement, the pain, stiffness, and swelling of the hands persisted and one month later both knees became similarly affected. The patient was referred to a rheumatologist.

Six months after the initial presentation, the patient developed two subcutaneous nodules on the left elbow. These were small, painless, firm, and immobile but not tender. A test for rheumatoid factor was now positive. The X- rays of the hands showed bony erosions in the metacarpal joints. This woman had definite X-ray evidence of rheumatoid arthritis and, in view of the continuing arthropathy, her treatment was changed to weekly low-dose methotrexate.

Although she received a maintenance dose of methotrexate, periodically the patient had flares of her disease. When flares occurred, prednisolone, ibuprofen, and, rabeprazole were prescribed, and another drug, leflunomide, was added.

Questions

1. With reference to the pathophysiology of polyarthritis, compare the clinical presentations of rheumatoid arthritis (RA) and osteoarthritis (OA).
2. What is the rationale for prescribing ibuprofen, methotrexate, prednisolone, rabeprazole, and leflunomide to this patient?
3. What are the ‘Disease-modifying antirheumatic drugs? How do they help in controlling the symptoms of rheumatoid arthritis?
4. What adverse effects would the nurse be monitoring for the patient who takes methotrexate and prednisolone?