The document is a case study of a 45-year-old female patient diagnosed with rheumatoid arthritis, detailing her symptoms, medical history, and treatment plan during a hospital stay from November 22 to November 27, 2017. Laboratory tests indicated abnormal blood parameters, leading to the diagnosis, with treatment strategies including medication and lifestyle modifications. The case study emphasizes the chronic and incurable nature of rheumatoid arthritis while highlighting the importance of managing symptoms and preventing joint damage.

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.: 17014842
Age: 45 years
Weight :42 kg
Department: Female Medicine Ward
Sex: Female
Unit: III
Date of Admission: 22/11/17
Date of Discharge: 27/11/17
Patient Demographics
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4.  C/O severe joint pain in both extremities, C/O Difficulty in breathing, weakness, headache and eye
pain, chest pain
PMHx : Hypertension since 1 year, hyperglycaemia since 1 month
MHX: Tab. Cefexime 200 mg 1-0-1, Syp. Lanopin (olanzapine) (HS), Tab. Pantop 40 mg 1-0-1, Tab.
Folmin 1-0-1, tab. Ecospirin 75 mg 0-1-0, tab. Metrogyl 400 mg 1-0-1, tab. Alpran 5 mg 0-0-1 →
since 10 days
Family Hx : NAD
Social Hx: Housewife
Pregnancy Status: No
ALLERGIES : NKA
Reason for admission
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5. PHYSICAL EXAMINATION:
 General: decreased appetite, disturbed sleep
 R: 16/min
 SPO2: 98%
 CVS: S1 S2 audible
 RS: Breathlessness
 CNS: oriented
 BP: 140/80 mm Hg
 PR: 96/min
 TEMP: 98 F
 PA: Soft
OBJECTIVES
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6. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 8.6 11.5-18 g%
WBC 17450 4000-11000 Cells/cu mm
Neutrophils 66 40-70 %
Eosinophils 01 1-6 /cu mm
Lymphocytes 00 20-40 /cu mm
Monocytes 30 2-10 /cu mm
Basophils 02 0-1 /cu mm
RBC 3.71*10^12 3.8-5.8*10^12 /cu mm
MCH 23.2 27-31 pg
PCV 29.5 40-54 %
Platelets 418000 1.5-4*10^5 /cu mm
MCV 79.5 78-100 fL
Se. Uric Acid 4.2 2.4-7.0 Mg/dL
Se. Creatinine 0.8 <1.5 Mg/dL
BSL (Random) 374 <120 Mg/dL
Lab. Investigation reports [first day]
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7. Others:
 22/11/17
Total protein: 6.1 g/dL (6-8)
MCHC: 29.2 g/dL (32-36)
RDW-CV: 14.2% (11-14)
USG: normal
CXR: Normal
2D Echo: IHD → LVF 40%
RF factor: IgM 128.31 Iu/mL (<10)
HbA1C → Glycolated Hb: 12.5% (<57%)
TSH: 0.30 uTU/mL (0.3-5.0)
Urine glucose: Trace
 23/11/17
ESR: 117 mm/hr (1-20)
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8. RA ?
PROVISIONAL DIAGNOSIS
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9.  A 45 year old female patient was admitted to Med. ward-3 with complaints of severe joint
pain in both extremities, Difficulty in breathing, weakness, headache and eye pain, chest
pain.
 Based on lab report, patient’s Hb, RBC count, PCV, MCHC, MCH, and RF levels are
abnormally decreased. ESR and WBC count are abnormally increased. 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: 96/min
R: 16/min
B.P.: 140/80 mmHg
SPO2: 98%
RS: Breathlessness
CVS: S1, S2 audible
CNS: oriented
PA: soft
C/O severe joint pain in both extremities, Difficulty in breathing, weakness, headache
and eye pain, chest pain
ADV: CBC, RF factor, HbA1C, TFT, Se. Creatinine
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13. Day 1 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone +
Sulbactam
100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac +
Paracetamol
50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole +
Domperidone
40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Methotrexate (on
Monday)
7.5mg P.O. Once weekly Rheumatoid Arthritis

14. DAY 2
T: normal
P: 87/min
R: 17/min
B.P.: 160/80 mmHg
SPO2: 99%
RS: Breathlessness
CVS: S1, S2 audible
CNS: oriented
PA: soft
C/O pain all over body, breathlessness
ADV: ESR, urine glucose
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15. Day 2 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone +
Sulbactam
100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac +
Paracetamol
50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole +
Domperidone
40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia

16. DAY 3
T: normal
P: 90/min
R: 16/min
B.P.: 140/90 mmHg
SPO2: 96%
RS: normal
CVS: normal
CNS: normal
PA: soft
C/O severe pain all over body, breathlessness, unconsciousness
ADV: ECG
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17. Day 3 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone +
Sulbactam
100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac +
Paracetamol
50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole +
Domperidone
40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia

18. DAY 4
T: normal
P: 86/min
R: 16/min
B.P.: 130/100 mmHg
SPO2: 98%
RS: breathlessness
CVS: normal
CNS: normal
PA: soft
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19. Day 4 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone +
Sulbactam
100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac +
Paracetamol
50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole +
Domperidone
40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia

20. DAY 5
T: normal
P: 90/min
R: 16/min
B.P.: 130/90 mmHg
SPO2: 99%
RS: breathlessness
CVS: normal
CNS: normal
PA: soft
C/O cough, difficulty in breathing
ADV: Neb. Asthalin
Syp. BGT 1tsf
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21. Day 5 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + Sulbactam 100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac + Paracetamol 50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole + Domperidone 40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia
Neb. Ipratropium bromide 2 ml Inh 1-0-1 Breathlessness
Syp. Bromohexin + Terbutalin + Guaifenesin 1 tsf P.O. 1-0-1 Cough Suppressant

22. DAY 6
T: normal
P: 89/min
R: 17/min
B.P.: 120/90 mmHg
SPO2: 98%
RS: AEBE clear
CVS: NAD
CNS: NAD
PA: soft
C/O difficulty in breathing
ADV: Neb. Ipratropium
Discharge
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23. Day 6 Medication chart
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DRUG DOSE ROUTE FREQUENCY INDICATIONS
Inj. Ceftriaxone + Sulbactam 100 mg + 500 mg I.V. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Diclofenac + Paracetamol 50 mg + 325 mg P.O. 1-0-0 analgesic
Tab. Rabeprazole + Domperidone 40 mg + 10 mg P.O. 1-0-1 GERD
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia
Neb. Ipratropium bromide 2 ml Inh 1-0-1 Breathlessness
Syp. Bromohexin + Terbutalin + Guaifenesin 1 tsf P.O. 1-0-1 Cough Suppressant

24. DISCHARGE MEDICATIONS
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 Adv.: PT daily
Hand mobilisation exercise
Both daily 2 times
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Cefexime 200 mg P.O. 1-0-1 Antibiotic
Tab. Hydroxychloroquine 200mg P.O. 1-0-1 Rheumatoid Arthritis
Tab. Atorvastatin + Aspirin 10 mg + 75 mg P.O. 1-0-0 Dyslipidaemia
Tab. Methotrexate (on Monday) 7.5mg P.O. Once weekly Rheumatoid Arthritis

25. TREATMENT PLAN:
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 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).

26.  CRP(C-reactive protein): NOT DONE
 Lipid Profile: NOT DONE
 Folic acid NOT PRESCRIBED
 NOT TREATED FOR HYPERTENSION AND HYPERGLYCAEMIA
 SERIOUS → USE ALTENATIVE:
➢ Diclofenac + Methotrexate: Diclofenac increases levels of Methotrexate by decreasing renal clearance. Avoid or
use alternate drug.
➢ Aspirin + Methotrexate: Aspirin increases levels of Methotrexate by decreasing renal clearance. Avoid or use
alternate drug.
 MONITOR CLOSELY:
➢ Hydroxychloroquine + Methotrexate: Hydroxychloroquine decreases levels of Methotrexate by reducing its renal
clearance.
➢ Rabeprazole + Methotrexate: Rabeprazole increases levels of Methotrexate by reducing its renal clearance.
➢ Diclofenac + Aspirin: Both increase anticoagulation and serum potassium.
➢
POINTS TO BE INTERVENED WITH THE DOCTOR
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27. PATIENT COUNSELING
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ABOUT DISEASE
RA:
 It is an incurable but controllable disease.

28. 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), under dose (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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29.  Exercise (Walking and Swimming)
 Diet Control
 Low salt Intake
 Balanced diet
 Avoid red meat
 Reduce Weight
 Avoid Cold
Life Style Modifications
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30. Diet Plan (DASH):
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31. 31