WELCOME

Presented by

Binuja.SS

CASE STUDY A 57 year old female was admitted to the hospital

with non healing ulceration of the left ankle and

oedema over the both lower limbs. Joints pain was

associated with intermittent fever. No history of

photosensitivity, decreased urine output, yellowish

discolouration of urine .No residual joint deformity.

HISTORY OF PRESENT ILLNESS Patient was admitted with non healing ulceration of

the left ankle and oedema over both lower limbs .

Joint pain associated with intermittent fever.

Alopecia present

History of dyspnoea

No residual joint deformity

PATIENT MEDICAL HISTORY Pain developed apparently before 5yrs back.

h/o hysterectomy (5 yrs back).

No h/o of

Hypertension

Diabetes mellitus

Jaundice

coronary Artery Diseases

PAST MEDICATION HISTORY

Not mentioned in the case sheet.

FAMILY HISTORY:

No relevant family history.

No history of similar illness in the past.

HABITS:

Anorexia

Sleep decreased

Bowel and bladder habits normal

PHYSICAL EXAMINATIONS

On general examination patient was conscious and oriented.

PR : 84 bpm BP : 120/90 mm of Hg Resp:12/mt Respiratory system :AEBE, clear CVS : s1 s2 normal

no murmur• CNS: No FND P0I0C0C0L0E0

Alimentry system: Soft non tenderNo hepatomegalyNo spleenomegaly

LABORATORY INVESTIGATION URINE:

Sugar : nil

Albumin: nil

Pus cell : 1-2 cells/ HPF

BLOOD

S.Bilirubin :0.3 mg/dl

SGOT : 34 IU[0-40]

SGPT : 35 IU[0-35]

ALP : 99 IU/L {<150}

STP : 6.5 gm% {5.5-7.5}

S.albumin: 3.3 mg/dl

BLOOD RBS : 115mg/ dL (80-120)

UREA:15mg/dL (5-20)

SERUM CREATININE: 0.7mg/dl (0.6-1.3 mg/dl)

SODIUM: 141mEq/l (135-145)

POTASSIUM: 3.2 mEq/l (3.6-5)

ESR: 100 mm/hr (<20mm/hr)

RF: Positive

PROVISIONAL DIAGNOSIS Rheumatoid Arthritis

Leg ischemia and chronic ulcer

TREATMENT SCHEDULEDAY1

Pedel oedema and non healing ulcers over L and R legFeverJoint painCVS: S1 S2 +Resp:AEBE

chest clear

1.I/O chart 4th hrly temp chart

2. Inj. Rantac 50 mg I/V BD(Ranitidine)

3.Inj.Cloxacillin 500 mg I/V Q6H4. Inj. Monocef 1 gm IV BD

(ceftriazone)5. Inj . Heparin 500 units I/V Q6H

6.T. Microcid 25 mg 1-0-1(Indomethacine)

7. T. Sazo 500 mg 1-0-1(sulfasalazine)

8.T. Mexit 2.5 mg 1-1-1 (Methotrexate)

9.T. Folvite 5 mg 1-0-0 (Folic acid)

10.T. Omnacortil 40 mg 1-0-0(Prednisolone) 30 mg 1-0-0

20 mg 1-0-011.T.Pletoz 50 mg 1-0-1

(cilostazol)

cotn.DAY 2

PR: 80/mtsBP: 150/90 mmHgChest: clear, AEBECVS: s1 ,s2 normal

Repeat 1-10 12. Inj.Methyl Prednisolone 1gm IV in 500ml NS

cotn.DAY 3

PR: 92/mts

BP: 140/80 mmHg

Chest: clear, AEBE

CVS: s1,s2 normal

Repeat 1-11

cotnDAY 4

PR: 84/mtsBP: 140/80 mmHgChest: clear, AEBECVS: s1s2 normalPain decreasesOedema decreasesafebrile

Repeat 1-11

cotn..DAY 5

PR: 74/mts

BP: 150/90 mm/Hg

Chest: clear, AEBE

CVS: s1s2 normal

Repeat 1-11

13. T. Warf 4 mg at 5 pm

contDAY 6

PR: 74/mtsBP: 150/90 mm/HgChest: clear, AEBECVS: s1s2 normal

Repeat 1-12

Patient was discharged on 7th day

1.T. Microcid 25 mg 1-0-1 2. T. Sazo 500 mg 1-0-1 3.T. Mexit 2.5 mg 1-1-1 (only on Sunday) 4.T. Folvite 5 mg 1-0-0 5.T. Omnacortil 40 mg 1-0-0

30 mg 1-0-020 mg 1-0-0

6. C. Megapen 500 mg 1-1-1-1 5d 7. Warf 4 mg at 5 pm 8. Aspirin 150 mg 0-1-0 9. Rapit 20 mg 1-0-0 10. T. Leflunamide 20mg od 11.Cilostazol 50 mg 1-0-1 Review on OPD with PT-INR ratio To attend dermatology OPD for chronic failure To attend rheumatology OPD

PROBLEM LIST Rheumatoid Arthritis

Leg ischemia and chronic ulcer

SOAP ANALYSIS Rheumatoid Arthritis

SUBJECTIVE A 57 year old female was admitted to the hospital

with non healing ulceration of the left ankle and

oedema over the both lower limbs .Joints pain was

associated with intermittent fever.

OBJECTIVE Patient on examination having pain and swelling of the

joints.

Early morning stiffness of the joints present.

Joint pain was associated with intermittent fever.

ASSESSMENT Patient presented with severe pain of leg and foot and

early morning stiffness of the joint.

oedema over lower limb characterised by itching

followed by ulceration.

Elevated level of ESR indicate the presence of

inflammatory condition.

Diffuse artereosclerotic changes showned by the

doppler test conform the leg ischaemia.

PLANAspirin and cilostazol is used as an antiplatelet agent

Coadministration of aspirin with cilostazol decreases

platelet aggregation compared with aspirin alone.

Rabeprazole is a proton pump inhibitor used for gastric

irritation.

Warfarin and Heparin is an anticoagulant used in the

prophyllaxis of VTE.

Methyl prednisolone, a corticosteroid used as an

antiinflammatory agents.

Ceftriazone Third Generation Cephalosporin antibiotic used

as an bactericidal agent.

cloxacillin is a pencillin derivatve used for the treatment of

skin infections.

Indomethacin is used as an antiinflammatory agent in the

treatment of RA.

Sulfasalazine is an anti-infective in the tratment of RA.

Methotrexate is an antimetabolite agent used in the treatment of

RA.

Methotrexate can cause folic acid deficiency so folic acid 5 mg

OD is supplemented during therapy.

Prednisolone is a corticosteroid used as an antiinflammatory

agents in RA.

ASSESMENT, PLAN AND FOLLOW UPDate Medical

Condition

Drug Therapy

Problem

Goal Current

Status

Intervention Follow Up Plan

31-7-13 RA Joints pain

associated with

intermittent

fever.

Reduce pain and inflammation

Joints pain

associated

with

intermittent

fever. And

inflammation

T. Microcid25 mg 1-0-1T. Sazo 500 mg 1-0-1T. Mexit 2.5 mg 1-1-1 , T. Folvite 5 mg 1-0-0 10.T. Omnacortil40 mg 1-0-030 mg 1-0-0

Return for check up.

ASSESMENT, PLAN AND FOLLOW UP

Date Medical

Condition

Drug Therapy

Problem

Goal Current

Status

Intervention Follow Up Plan

3-8-13 RA Joints pain

associated

with

intermittent

fever.

Reduce pain and inflammation

Pain decreasesOedemadecreasesafebrile

Repeat the above medications

Return for check up.

4-8-13 RA Joints pain

associated

with

intermittent

fever.

Reduce pain and inflammation

Pain decreasesOedemadecreasesafebrile

Repeat the above medications

Return for check up.

5-8-13 RA Joints pain

associated

with

intermittent

fever.

Reduce pain and inflammation

Pain decreasesOedemadecreasesafebrile

Repeat the above medications

Return for check up

6-8-13 RA Joints pain

associated

with

intermittent

fever.

Reduce pain and inflammation

Relieved discharge withadvice

Repeat the above medications

Dischargewith advice

COMMENTS ON THERAPY A disease modifying antirheumatic drug should be started

within the first 3 months of symptom onset. Early introduction

of DMARD results in a more favourable outcome.(As per

DIPIRO Pharmacotherapeutic Approach,7th edition,page

no:1510).

Combination therapy is beneficial than single drug therapy.

Medical Insurance is to be taken for affording medical

expenses.

PATIENT COUNSELLING Take adequate rest it will relieves the stress on

inflammed joints and prevent further destruction. But donot take too much rest and immobility it will lead to muscle and joint damage.

Do heat, cold or electrotherapy to reduce pain and swelling in the joints.

Do exercises as directed by the physiotherapist to strengthen the joints and to minimize joint damage.

Use supportive devices like walkers, splints to protect joints from excessive stress.

You should not increase weight.

Avoid conditions that aggravates RA like cold climates, as well as foods like cauliflower, beef, wheat, salts, saturated fats, milk and other dairy products, fried foods, eggs, meat and coffee

Continue taking medications without any fail.

Maintain adequate fluid intake to prevent kidney damage.

Avoid prolonged exposure to sunlight, use a sunscreen when exposed to sunlight.

Take good mouth care to prevent infection in the oral cavity

Avoid exposure to people with infection and also report signs of infection immediately.

Don't vaccinate during therapy.