patient case presentation on rheumatoid arthritis

1. Case Presentation On
Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II
By :- Teena
1412818
Pharm.D 3rd yr

2. Case Description
• A 48 yr old Female admitted to MMIMSR hospital on 09.02.2015 with the
C/O
 pain in B/L lower limbs & involves all small & large joints.
 Deformity +nt
 Tenderness +nt in all joints
 Blackening of Lt 3rd finger of foot * since 7 days
 Swelling over face & lower limbs* since 1 month
O/E
 conscious, oriented, CVS – S1,S2(N)
 Lt knee contracted , moon like face , excess fat deposition in upper body,
facial pigmentation , scars/marks over Lt leg below knee
• P/A- Soft, ND/NT
• Past medical history: RA (since 20 YRS)
• Past medication history: took ayurvedic medicines
• Family and Social History: non smoker, no addiction , vegetarian, sleep &
appetite decrease

3. Physical Investigation
Vital
s
9
feb
10
feb
11
feb
12
feb
13
feb
14
feb
15
feb
16
feb
17
feb
18
feb
19
feb
BP(mm
/Hg)
160/
90
130/
80
140/9
0
130/9
0
140/
80
160/
100
140/
80
140/
90
130/
90
150/
90
160/
90
Pulse
Rate
(/min)
90 80 124 100 120 100 90 120 112 104 128
Resp
Rate
(/min)
18 18 18 18 16 18 18 18 20 18 18
Temp
(F)
Afeb. Afeb. Afeb. Afeb. Afeb. Afeb. Afeb. Afeb Afeb Afeb Afeb
FBS - - 143 163 107 135 97 59 93 80 71

4. Laboratory Investigation
Constituents Detected values Normal Range
DLC
Polymorphs 64 40 – 75%
Lymphocytes 33 20 – 40%
Eosinophils 02 02 – 6%
Monocytes 01 02 – 10%
Basophils 00 00 – 1%
ESR 40
0 – 20mm/1st hr
HB 10.8 12 – 15gm %
Platelet count 2.3 1.5 – 4.5 lac/ cumm
TLC 5700 4000 – 10000 / cumm

5. LFT
Bilirubin Total
0.72 0.20 – 1.00 mg/dl
Bilirubin Direct
0.24 0.10 – 0.30 mg/dl
SGOT 70 5 – 40 IU/L
SGPT 90 5 – 35 IU/L
Alkaline Phosphatase 181 5 – 112 IU/L
RFT
Urea
44.38 15 – 40 mg/dl
Creatinine 0.76 0.40 – 1.40 mg/dl
Sodium 139 135 – 145 mEq/L
Chloride 108 96 – 106 mmol/L
Potassium 3.4 3.50 – 5.00 mEq/L

6. URINE CULTURE
• Vol – 40ml
• Color – pale yellow
• Urine Albumin – NIL
• Urine sugar fasting – NIL
• Pus cell – 4-5 HPF
• Epithelial cell – 1-2 HPF
• Crystals- NIL
• Cast - NIL

7. Specific Test
 USG Abdomen
Impression : fatty liver with hepatomegaly
 COLOR DOPPLER TEST
Left leg shows atherosclerotic changes in
lower limb arteries .
 HBA1C : 8.7%

8. Diagnosis
Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II

9. Treatment
DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequency
Tab. HCQS
(hydroxychloroquin
e )
200mg
oral
9/02 19/02 Anti
Rheumatoid
agent
BD
Tab. Methotrexate 7.5mg
Oral
9/02 -- Anti
Rheumatoid
agent
Once a
week
Cap. Cyra-D
(Rabeprazole +
Domperidone)
50mg
Oral
9/02 19/02 PPI+
antiemetics
OD
Cap. A to Z
Oral
9/02 19/02 Multivitamin OD
Tab. Folvite
(Folic acid
)
5 mg
Oral
9/02 19/02 supplement OD

10. DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequency
Tab. Vorth
(Tapentadol)
50mg
Oral
9/02 16/02 Analgesic OD
Tab. Shelcal
(Calcium + vit D)
500mg
Oral
9/02 19/02 Supplement OD
Tab. Dolo
( PCM)
650mg
Oral
12/02 13/02 Anti pyretic +
Anlagesic
BD
Tab. Ecospirin AV
( Aspirin +
Atorvastatin )
oral
12/02 12/02 Anti platelet
+ Anti
Hyperlipide
mic agent
HS
Tab .Metformin 500mg
Oral
11/02 19/02 Oral
Hypoglycemi
c agent
OD

11. DRUGS + API Dose +
Route
Date of
Start
Date of
Stop
Category Freque
ncy
Tab. Melson
(predinisolone)
16mg
Oral
13/02 19/02 Corticosteroid BD
Tab. Acuclav (
Augmentin)
625 mg
Oral
14/02 13/03 Anti biotic OD
Tab .
Telmisartan
40mg
oral
14/02 19/02 Anti
hypertensive
OD
Tab .
Carvedilol* Oral
19/02 17/02 Anti
hypertensive
OD
 On 14 feb 2015, there was a surgery call and 3rd
toe of left foot is removed as there is 80% sensory
loss

12. SOAP NOTE
• SUBJECTIVE
• Patient came with complaints of
 pain in B/L lower limbs & involves all small &
large joints.
 Deformity +nt
 Tenderness +nt in all joints
 Blackening of Lt 3rd finger of foot * since 7 days
 Swelling over face & lower limbs* since 1
month

13. OBJECTIVE
• To correct the abnormal values of :-
 Monocytes - 01
 ESR - 40
 HB - 10.8
 SGOT - 70
 SGPT - 90
 Alkaline Phosphatase - 181
 Urea - 44.38
 Chloride - 108

14. ASSESSMENT
• The patient on basis of subjective and
objective information was diagnosed with
Lt Foot Gangrene + Drug induced Cushing
syndrome + Rheumatoid arthritis + DM II

15. PLAN
• SHORT TERM GOALS
 Relieve symptoms
• LONG TERM GOALS
 Delaying or halting the
progression of RA
 Controlling the disease
from getting more
complicated
 Controlling sudden
elevation in blood
glucose level.

16. Patient Counselling
 Adhere to the medication
 Periodic checkup.
 Mild exercise to improve the range of joint
motion.
 Take adequate rest .
 Physiotherapy recommended .

17. Conclusion
• Clinical features are suggestive of steroidal
toxicity.
• Melson being a corticosteroid is given in lower
dose to releive withdrawal symptoms.
• With prolonged use, Mtx can cause liver disease.