A 35-year old female patient was admitted to the female medicine ward with complaints of blackish discoloration of left toe, difficulty in walking since 5-6 months, joint pain since 15-20 years. she had a past history of malaria, convulsions and typhoid before 3-4 years.

1. A Case Study On
Rheumatoid Arthritis
Ajita Sadhukhan
- Pharm D. 3rd year
- Roll No. : 1
- Enrolment No. : 150821207001
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2.  RHEUMATOID ARTHRITIS: It is a chronic systemic autoimmune disorder
causing a symmetrical polyarthritis.
DEFINITION:2

3. IPD No.: 17010586
OPD No.:17118443
Age: 35 years
Weight :56 kg
Department: Female Medicine Ward
Sex: Female
Unit: I
Date of Admission: 28/8/17
Date of Discharge: 1/9/17
Patient Demographics3

4.  C/O Blackish discoloration of left toe
 C/O Difficulty in walking since 5-6 months
 C/O Joint pain since 15-20 years, joint abnormality
PMHx : Malaria and typhoid fever before 3-4 years, convulsion before 3-4 years on RX, RA since
15-20 years
MHX: Ferrous Ascorbate, folic acid, vit. B 12, Zinx Tab. (Rajra M12), Calcium, Vit. Essential trace
element (Tab. Cal – RA), Hydroxychloroquine Sulphate 200 mg (rutor), Aceclofenac
sustained release tab. (starnac – 200 SR), leflunomide 20 mg ( Tab. Fluna -20) → taking since
6 months but from 28/8/17 stopped
Family Hx : Elder sister → RA
Social Hx: Housewife
Pregnancy Status: No
ALLERGIES : NKA
Reason for admission
4

5. PHYSICAL EXAMINATION:
 R: 18/min
 CVS: S1 S2 clear, heard
 RS: AEBE clear
 CNS: Conscious, oriented
 BP: 110/80 mm Hg
 PR: 68/min
 TEMP: 98 F
 PA: Soft
OBJECTIVES5

6. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.9 11.5-18 g%
WBC 8180 4000-11000 Cells/cu mm
Neutrophils 66 40-70 %
Eosinophils 14 1-6 /cu mm
Lymphocytes 16 20-40 /cu mm
Monocytes 04 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 3.42*10^12 3.8-5.8*10^12 /cu mm
ESR 60 1-20 mm/hr
PCV 31.5 40-54 %
MCHC 31.4 33-36 g/dL
Se. Urea 22 10- 45 Mg/dL
Se. Uric Acid 2.5 2.4-7.0 Mg/dL
Se. Creatinine 0.6 <1.5 Mg/dL
RF (Rheumatoid Factor) IgM 64 <10 IU/mL
Lab. Investigation reports [first day]
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7. Others:
 29/8/17
CRP: 24 mg/L (<60)
Se. urea: 22 mg/dL (15-24)
Se. Creatinine: 0.6 mg/dL (0.5-1.5)
Se. Uric acid: 2.5 mg/dL (3.5-7.2)
LFT: normal
TSH: 6.64 uIU/mL (0.3-5.0)
 30/8/17
USG: Left ankle normal
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8. RA
PROVISIONAL DIAGNOSIS8

9.  A 35 year old female patient was admitted to Med. ward-1 with complaints of
blackish discoloration of left toe, difficulty in walking since 5-6 months, joint pain
since 15-20 years, joint abnormality.
 Based on lab report, patient’s Hb, RBC count, ESR, PCV, MCHC and RF levels are
abnormally decreased. Hence, patient was diagnosed with Rheumatoid Arthritis.
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10. FINAL DIAGNOSIS:
RA
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11. For Rheumatoid Arthritis:
It is an incurable disease so focus to stop inflammation (put
disease in remission).
 Relieve symptoms.
Prevent joint and organ damage.
GOALS OF TREATMENT
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12. DAY 1
T: 98 F
P: 70/min
R: 20/min
B.P.: 110/80 mmHg
SPO2: 99%
ADV: CBC, TSH, ANA, USG ankle, RA factor, Widal test
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13. Day 1 Medication chart
13DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. DNS 1 pint/ 250 ml I.V. 1-0-1 Electrolyte supplement
Inj. Multivitamin 10ml I.V. 0-1-1 Vitamin supplement
Inj. Ranitidine 25mg/12 ml I.V. 1-0-1 To prevent acidity
Inj. Ondansetron 4 mg/ 12 ml I.V. TDS Nausea and vomiting
Tab. Diclofenac +
Paracetamol
50 mg P.O. 1-0-1 analgesic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 40 mg P.O. 1-0-0 Rheumatoid Arthritis
Tab. Methotrexate (on
Monday)
7.5mg P.O. Once weekly Rheumatoid Arthritis
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Paracetamol 500 mg P.O. 1-1-1 Anti-pyretic, analgeisc

14. DAY 2
T: 98 F
P: 78/min
R: 20/min
B.P.: 110/70 mmHg
SPO2: 98%
ADV: TSH, ANA profile, surgical reference for left big toe gangrene, CRP, Carotid
Doppler
14

15. Day 2 Medication chart
15
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. DNS 1 pint/ 250 ml I.V. 1-0-1 Electrolyte supplement
Inj. Ranitidine 25mg/12 ml I.V. 1-0-1 To prevent acidity
Inj. Ondansetron 4 mg/ 12 ml I.V. TDS Nausea and vomiting
Tab. Diclofenac +
Paracetamol
50 mg P.O. 1-0-1 analgesic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 40 mg P.O. 1-0-0 Rheumatoid Arthritis
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Paracetamol 500 mg P.O. 1-1-1 Anti-pyretic, analgeisc

16. DAY 3
T: normal
P: 74/min
RS: clear
B.P.: 90/60 mmHg
SPO2: 98%
c/o: dry cough
ADV: Syp. DPC 2tsf TDS
B/L – DPA pulsation not felt
16

17. Day 3 Medication chart
17 DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. DNS 1 pint/ 250 ml I.V. 1-0-1 Electrolyte supplement
Inj. Multivitamin 10ml I.V. 0-1-1 Vitamin supplement
Inj. Ranitidine 25mg/12 ml I.V. 1-0-1 To prevent acidity
Inj. Ondansetron 4 mg/ 12 ml I.V. TDS Nausea and vomiting
Tab. Diclofenac + Paracetamol 50 mg P.O. 1-0-1 analgesic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 40 mg P.O. 1-0-0 Rheumatoid Arthritis
Syp. Cholrpheniramine +
Dextromethorphan + Phenylephrine)
2 tsf P.O. TDS Cough suppressant
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Paracetamol 500 mg P.O. 1-1-1 Anti-pyretic, analgesic

18. DAY 4
T: normal
P: 74/min
RS: clear
B.P.: 90/60 mmHg
SPO2: 98%
c/o: dry cough
ADV: febrinil 1 amp i.v. stat
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19. Day 4 Medication chart
19 DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. DNS 1 pint/ 250 ml I.V. 1-0-1 Electrolyte supplement
Inj. Multivitamin 10ml I.V. 0-1-1 Vitamin supplement
Inj. Ranitidine 25mg/12 ml I.V. 1-0-1 To prevent acidity
Inj. Ondansetron 4 mg/ 12 ml I.V. TDS Nausea and vomiting
Tab. Diclofenac + Paracetamol 50 mg P.O. 1-0-1 analgesic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 40 mg P.O. 1-0-0 Rheumatoid Arthritis
Syp. Cholrpheniramine +
Dextromethorphan + Phenylephrine)
2 tsf P.O. TDS Cough suppressant
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Paracetamol 500 mg P.O. 1-1-1 Anti-pyretic, analgesic

20. DAY 5
T: 100 F
P: 82/min
B.P.: 120/80 mmHg
SPO2: 98%
c/o: cough
Patient discharged.
20

21. Day 5 Medication chart
21 DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. DNS 1 pint/ 250 ml I.V. 1-0-1 Electrolyte supplement
Tab. Ciprofloxacin 500 mg P.O. 1-0-1 antibiotic
Tab. Ranitidine + Ondansetron 4 mg P.O. 1-1-1 To prevent acidity and
emesis
Tab. Disodium hydrogen 40 mg in ½ glass water P.O. 2-2-2 GERD
Tab. Diclofenac + Paracetamol 50 mg P.O. 1-0-1 analgesic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 40 mg P.O. 1-0-0 Rheumatoid Arthritis
Syp. Cholrpheniramine +
Dextromethorphan + Phenylephrine)
2 tsf P.O. TDS Cough suppressant
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Paracetamol 500 mg P.O. 1-1-1 Anti-pyretic, analgesic

22. DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Prednisolone 20 mg P.O. 1-0-0 Rheumatoid Arthritis
Tab. Folic Acid 5mg P.O. 1-0-1 Folic acid supplement
Tab. Phenytoin 300 mg P.O. 0-0-1 Anti-convulsant
Tab. Methotrexate (on
Monday)
5mg P.O. Once weekly Rheumatoid Arthritis
DISCHARGE MEDICATIONS (follow up after 14 days. After
completing the dose come again with all reports.)
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23. TREATMENT PLAN:
23
 For Rheumatoid Arthritis:
❖ Non-pharmacological treatment:
➢ Physiotherapy
➢ Swimming
➢ Free hand exercise
➢ Avoid cold
❖ Pharmacological therapy:
➢ There are three general classes of drugs commonly used in the treatment of rheumatoid
arthritis: non-steroidal anti-inflammatory agents (NSAIDs), corticosteroids, and disease
modifying anti-rheumatic drugs (DMARDs).

24.  No treatment has been done for increased levels of TSH
 SERIOUS → USE ALTERNATIVE:
➢ Diclofenac + Methotrexate: Diclofenac increases levels of methotrexare by decreasing its renal clearance.
➢ Ciprofloxacin + Ondansetron: both increase QT interval . ECG monitoring is recommended
 MONITOR CLOSELY:
➢ Hydroxychloroquine + Methotrexate: Hydroxychloroquine decreases levels of Methotrexate by reducing its
renal clearance.
➢ Diclofenac + Prednisolone: either increases toxicity of the other by pharmacodynamic synergism,
➢ Diclofenac + Ciprofloxacin: increased risk of CNS stimulation and seizures.
➢ Phenytoin + Ondansetron: Phenytoin will decrease the level or effect of ondansetron by affecting hepatic/
intestinal enzyme CYP3A4 metabolism.
➢ Phenytoin + Methotrexate: increased toxicity of methotrexate.
➢ Phenytoin + Prednisolone: Phenytoin will decrease the level or effect of prednisolone by affecting hepatic/
intestinal enzyme CYP3A4 metabolism and P-glycoprotein efflux transporter.
➢ Prednisolone + Ciprofloxacin: Increased risk of tendon rupture.
➢ Ciprofloxacin + Methotrexate: inhibit renal tubular transport of Methotrexate → toxicity
POINTS TO BE INTERVENED WITH THE DOCTOR
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25. PATIENT COUNSELING
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ABOUT DISEASE
RA:
 It is an incurable but controllable disease.

26. About Medications:
 Dose of drugs
 Frequency of dose
 Route of administrations such as I.V, I.M., t/d, s/c, P.O., S/L.
 Counselling regarding overdose (may cause toxicity), underdose
(submaximal or no response) and missing of dose of medication. E.G. If a
dose is missed, then the patient is to be advised to go for the next dose,
otherwise toxicity of drug may occur.
 Contraindications
 Drug interactions (drug-drug, drug-food)
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27.  Exercise (Walking and Swimming)
 Physiotherapy
 Diet Control
 Low salt Intake
 Balanced diet
 Avoid red meat
 Reduce Weight
 Avoid Cold
Life Style Modifications27

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