NR 602 Soap Note -Juvenile RA

NR 602 Soap Note -Juvenile RA

NR 602 Soap Note -Juvenile RA

Juvenile Idiopathic Arthritis (Juvenile RA)

JIA, formerly known as juvenile rheumatoid arthritis (JRA), now encompasses several disorders that have a common feature of arthritis (e.g., enthesitis-related arthritis and psoriatic arthritis) and had not been identified under the nomenclature of JRA (Wu et?al, 2011). The diagnosis of JIA requires a persistent arthritis for more than 6 weeks in a pediatric patient younger than 16 years old. Table 25-1 shows the most current classification system.

TABLE 25-1

Juvenile Idiopathic Arthritis Subtypes and Clinical Joint Characteristics

Juvenile Idiopathic Arthritis Subtype	Clinical Joint Characteristics
Oligoarticular	Four or less joints with persistent disease never having more than four-joint involvement and extended disease progressing to more than four joints within the first 6 months
Polyarticular (RF negative)	Five or more joints with symmetrical involvement
Polyarticular (RF positive)	Symmetric involvement of both small and large joints with erosive joint disease
Systemic	Either polyarticular or oligoarticular disease
Enthesitis-related arthritis	Weight-bearing joints involved especially hip and intertarsal joints and a history of back pain, which is inflammatory in nature or sacroiliac joint involvement
Psoriatic arthritis	Asymmetric or symmetric small or large joints
Undifferentiated

RF, Rheumatoid factor.

The underlying cause of most forms of JIA is unclear; however, it is a heterogenous disorder. It is likely environmentally induced in genetically predisposed …

NR 602 Soap Note -Juvenile RA

The presence of autoantigens from cartilage and joint tissue leads to activation of the T cells and results in release of proinflammatory …

NR 602 Soap Note -Juvenile RA

Clinical Findings

History

The major complaints in all forms of JIA are from the arthritis characterized by:

• Pain—generally a mild to moderate aching
• Joint stiffness—worse in the morning and after rest; arthralgia may occur during the day
• Joint effusion and warmth

Systemic symptoms are found more commonly in systemic and polyarticular subtypes and include anemia, anorexia, fever, fatigue, lymphadenopathy, salmon-colored rash (SJIA), and weight loss. Growth abnormalities can result in localized growth disturbances, including premature fusion of the epiphyses, bony overgrowth (rheumatoid nodules), and limb-length discrepancies.

NR 602 Soap Note -Juvenile RA

Physical Examination

Associated features are:

• Non-migratory monoarticular or polyarticular involvement of large or proximal interphalangeal joints for more than 3 months
• Systemic manifestations—fever, salmon-colored rashes, leukocytosis, serositis, lymphadenopathy, and rheumatoid nodules

Less commonly seen are ocular disease (e.g., iridocyclitis, iritis, or uveitis), pleuritis, pericarditis, anemia of chronic disease, fatigue, and growth failure, or leg-length discrepancy if the arthritis is unilateral.

Key physical findings are:

• Swelling of the joint …
• …
• …
• …

There are five major types of JIA (Gowdie and Tse, 2012):

1. Oligoarticular pattern: This type of JIA involves …
2. Polyarticular pattern: This involves five or more joints and is divided …
3. SJIA: This is characterized by arthritis in one or more joints for 6 weeks’ duration in a child younger than 16 years old …

4. Enthesitis-related JIA: This typically entails arthritis of the lower limbs especially the hip and intertarsal joints with the sacroiliac joints …
5. Psoriatic arthritis: This is more common between the ages of 2 and 4 and again between 9 to 11 years old. There is usually a family history of psoriasis, or the child has psoriasis; however, the arthritis can precede the psoriasis by years. There can be dactylitis or a sausage-like swelling of the digits; involvement in the small digits is not uncommon.

NR 602 Soap Note -Juvenile RA

Diagnostic Studies

JIA is a diagnosis of exclusion. The diagnosis is based on physical findings and history of arthritis lasting for 6 weeks or longer. There is no diagnostic laboratory test for JIA. Most children with oligoarticular …

Differential Diagnosis

The various causes of monoarticular arthritis are part of the differential diagnosis. However, Lyme disease must be excluded and other differentials, including tumors, leukemia, cancer, bacterial infections, toxic synovitis, rheumatic fever, SLE, spondyloarthropathies, inflammatory bowel disease, septic arthritis, and chondromalacia patellae, need to be carefully considered.

NR 602 Soap Note -Juvenile RA

Management

A specialist in pediatric rheumatology should follow children with severe involvement. Ophthalmology referral and evaluation is critical in a child with a positive ANA. Uveitis needs immediate ophthalmologic management. It is most common in oligoarticular JIA and is highly associated with a positive ANA. Other pediatric subspecialists, such as orthopedists, pain management specialists, and cardiologists, may be consulted as needed. Therapy depends on the degree of local or systemic involvement.

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The main treatment goals are to suppress inflammation, preserve and maximize joint function, prevent joint deformities, …

Pharmacologic agents commonly used in the management of JIA include the following (Gowdie and Tse, 2012):

• NSAIDs: Children with oligoarthritis generally respond well to NSAIDs (Taketomo et?al, 2014).
• Ibuprofen: …

NR 602 Soap Note -Juvenile RA

Complications and Prognosis

Systemic involvement can include iridocyclitis, uveitis, pleuritis, pericarditis, anemia, fatigue, and hepatitis. Residual joint damage caused by granulation of tissue in the joint space can occur. Children most likely to develop permanent crippling disability include those with hip involvement, unremitting synovitis, or positive-RF test.

The course of the disease is variable, and there is no curative treatment. Again, early aggressive treatment is critical; therefore, referral to a specialist is important. After an initial episode, the child may never have another episode, or the disease may go into remission and recur months or years later. The disease process of JIA wanes with age and completely subsides in 85% of children; however, systemic onset, a positive RF, poor response to therapy, and the radiologic evidence of erosion are associated with a poor prognosis. Onset of disease in the teenage years is related to progression to adult rheumatoid disease.