The document presents a case study of a 35-year-old female patient diagnosed with rheumatoid arthritis, detailing her symptoms, medical history, laboratory findings, and treatment plan. Despite being an incurable disease, the focus is on controlling symptoms, preventing joint damage, and managing inflammation through pharmacological and non-pharmacological therapies. The treatment includes medications like hydroxychloroquine, methotrexate, and prednisolone, along with lifestyle modifications and follow-up care protocols.

1. A Case Study
On
Rheumatoid
Arthritis
Ajita Sadhukhan
- Pharm D. 3rd year
- Roll No. : 1
- Enrolment No. : 150821207001
1

2. – RHEUMATOID ARTHRITIS: It is a chronic systemic autoimmune disorder causing
a symmetrical polyarthritis.
DEFINITION:2

3. IPD No.: 17015431
Age: 35 years
Weight :47 kg
Department: Female Medicine Ward
Sex: Female
Unit: I
Date of Admission: 04/12/17
Date of Discharge: 13/12/17
Patient Demographics3

4. – C/O bodyache with weakness, pain in knee joint since 2-3 months, difficulty in walking
PMHx : TB lymphadenopathy, RA
MHX: N/A
Family Hx : NAD
Social Hx: Housewife
Pregnancy Status: No
ALLERGIES : NKA
Reason for admission4

5. PHYSICAL EXAMINATION:
– General: decreased appetite
– R: 20/min
– SPO2: 98%
– CVS: S1 S2 normal
– RS: AEBE clear
– CNS: conscious
– BP: 120/80 mm Hg
– PR: 92/min
– TEMP: normal
– PA: Soft
OBJECTIVES5

6. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 5.4 11.5-18 g%
WBC 5610 4000-11000 Cells/cu mm
Neutrophils 76 40-70 %
Eosinophils 02 1-6 /cu mm
Lymphocytes 18 20-40 /cu mm
Monocytes 04 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 4.03*10^12 3.8-5.8*10^12 /cu mm
MCH 13.4 27-31 pg
PCV 19.9 40-54 %
Platelets 719000 1.5-4*10^5 /cu mm
MCV 49.5 78-100 fL
Se. Uric Acid 4.2 2.4-7.0 Mg/dL
Se. Creatinine 0.8 <1.5 Mg/dL
BSL (Random) 74 40-140 Mg/dL
Lab. Investigation reports [first day]6

7. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.7 11.5-18 g%
WBC 7110 4000-11000 Cells/cu mm
Neutrophils 83 40-70 %
Eosinophils 01 1-6 /cu mm
Lymphocytes 15 20-40 /cu mm
Monocytes 01 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 5.57*10^12 3.8-5.8*10^12 /cu mm
MCH 17.4 27-31 pg
PCV 33.6 40-54 %
Platelets 478000 1.5-4*10^5 /cu mm
MCV 60.4 78-100 fL
MCHC 28.9 32-36 g/dL
Lab. Investigation reports [3rd day]7

8. LABORATORY PARAMETERS OBSERVED VALUE NORMAL RANGE UNIT
Hb 9.5 11.5-18 g%
WBC 11290 4000-11000 Cells/cu mm
Neutrophils 82 40-70 %
Eosinophils 01 1-6 /cu mm
Lymphocytes 14 20-40 /cu mm
Monocytes 03 2-10 /cu mm
Basophils 00 0-1 /cu mm
RBC 5.42*10^12 3.8-5.8*10^12 /cu mm
MCH 17.5 27-31 pg
PCV 33.0 40-54 %
Platelets 469000 1.5-4*10^5 /cu mm
MCV 60.8 78-100 fL
MCHC 28.8 32-36 g/dL
Lab. Investigation reports [4th day]8

9. Others:
Se. Na+: 135 mEq/L (130-145)
Se. K+: 5.0 mEq/L (3-5)
Uric Acid: 6.0 mg/dL (10-45)
Se. Creatinine: 0.5 mg/dL (0.4-1.5)
MCHC: 27.1 g/dL (32-36)
RDW-CV: 92.5% (11-14)
USG of abdomen and pelvis: normal
TSH: 7.95 mcIU/mL (0.3-5.0)
ESR: 19.9 mm/hr (1-20)
Se. Fe: 24.8 mcg/dL (50-170)
RF: 60.8 IU/mL (<10)
Reticulocyte Count: 0.5% (0.5-2.5)
ANA profile immunodot: +ve
Urine analysis: normal
Urine pregnancy test: -ve
Se. LDH: 276.2 UL (103-227)
Se. Vit B12: 442 pg/mL (240-900)
Blood group: B +ve
9

10. RA ?
PROVISIONAL DIAGNOSIS10

11. – A 35 year old female patient was admitted to Med. ward-1 with complaints of bodyache
with weakness, pain in knee joint since 2-3 months, difficulty in walking.
– Based on lab report, patient’s Hb, RBC count, Lymphocytes, PCV, MCV, Se. Fe, MCHC, MCH,
and RF levels are abnormally decreased. ESR, Neutrophils, RDW-CV, TSH Platelets and WBC
count are abnormally increased. ANA Profile Immunodot was positive. Hence, patient was
diagnosed with Rheumatoid Arthritis.
11

12. FINAL DIAGNOSIS:
RA
12

13. 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 TREATMENT13

14. DAY 1
T: normal
P: 100/min
R: 20/min
B.P.: 130/80 mmHg
SPO2: 97%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O bodyache with weakness, pain in knee joint since 2-3 months, difficulty in walking
ADV: RBS, ANA level, Se. Fe, Se. Vit B12, Reticulocyte Count, LDH, Se. TSH, CBC, Blood Group
14

15. Day 1 Medication chart15
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Methotrexate (on
Monday)
2.5mg P.O. Once weekly Rheumatoid Arthritis
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. PCV 2 pints I.V. - Increase Hb
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

16. DAY 2
T: normal
P: 80/min
R: 19/min
B.P.: 140/90 mmHg
SPO2: 97%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O anorexia, pain in umbilical region
16

17. Day 2 Medication chart17
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin +
Clavulonic Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

18. DAY 3
T: normal
P: 80/min
R: 20/min
B.P.: 120/70 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
C/O constipation, stool not passed since 2 days
Adv.: ANA profile, CBC, Rheumatologist reference
18

19. Day 3 Medication chart19
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin +
Clavulonic Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis

20. DAY 4
T: normal
P: 93/min
R: 20/min
B.P.: 130/90 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
20

21. Day 4 Medication chart21
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

22. DAY 5
T: normal
P: 85/min
R: 19/min
B.P.: 120/90 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: NAD
22

23. Day 5 Medication chart23
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

24. DAY 6
T: normal
P: 94/min
R: 20/min
B.P.: 100/80 mmHg
SPO2: 99%
RS: NAD
CVS: NAD
CNS: NAD
PA: soft
c/o: acidity
24

25. Day 6 Medication chart25
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 200 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Inj. Amoxicillin + Clavulonic
Acid
1.2 ml I.V. 1-1-1 antibiotic
Inj. Tramadol 1 amp in 100 ml NS I.V. SOS analgesic
Inj. Ranitidine 1 amp I.V. 1-1-1 Prevents acidity
Inj. Ondansetron 1 amp I.V. 1-1-1 Prevents emesis
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

26. DISCHARGE MEDICATIONS26
– Adv.: follow up after 3 weeks with CBC, ESR, CRP, Se. Creatinine, SGPT
DRUG DOSE ROUTE FREQUENCY INDICATIONS
Tab. Hydroxychloroquine 300 mg P.O. 1-0-1 Painkiller
Tab. Prednisolone 30 mg P.O. 1-0-0 Painkiller
Tab. Calcium + Vit. D3 250 mg P.O. 1-0-1 Calcium & Vit. D
supplement
Tab. Rabeprazole 40 mg P.O. 1-0-1 GERD
Tab. Sulfsalazine 500 mg P.O. OD Painkiller
Tab. Folic acid 5 mg P.O. 0-1-0 (except on Monday) Folate deficiency

27. TREATMENT PLAN:27
– 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).

28. – CRP(C-reactive protein): NOT DONE
– SERIOUS → USE ALTENATIVE:
➢ Sulfasalazine + Methotrexate: Sulfasalazine increases levels of Methotrexate by decreasing renal clearance.
– 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.
➢ Amoxicillin + Sulfasalazine: either increases levels of the other by plasma protein binding competition and
decreasing renal clearance.
➢ Amoxicillin + Methotrexate: Amoxicillin increases levels of Methotrexate by reducing its renal clearance.
➢ Sulfasalazine + Prednisolone: Either increases toxicity of the other by pharmacodynamics synergism.
POINTS TO BE INTERVENED WITH THE DOCTOR28

29. PATIENT COUNSELING29
ABOUT DISEASE
RA:
– It is an incurable but controllable disease.

30. 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)
30

31. – Exercise (Walking and Swimming)
– Diet Control
– Low salt Intake
– Balanced diet
– Avoid red meat
– Reduce Weight
– Avoid Cold
Life Style Modifications31

32. 32