A 57-year-old female was admitted with non-healing ulceration of the left ankle, edema of both lower limbs, and joint pain with intermittent fever. Her history and examinations were consistent with rheumatoid arthritis. She was treated with aspirin, prednisolone, methotrexate, folic acid, and other medications. Her joint pain and edema improved over her 6-day hospital stay, and she was discharged on medications with follow-up planned.

1. WELCOME

2. Presented by
Binuja.SS

3. 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.

4. 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

5. 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.

6. FAMILY HISTORY:
No relevant family history.
No history of similar illness in the past.
HABITS:
Anorexia
Sleep decreased
Bowel and bladder habits normal

7. 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 tender
No hepatomegaly
No spleenomegaly

8. 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

9. 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

10. PROVISIONAL DIAGNOSIS
Rheumatoid Arthritis
Leg ischemia and chronic ulcer

11. TREATMENT SCHEDULE
DAY1
Pedel oedema and non healing
ulcers over L and R leg
Fever
Joint pain
CVS: 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 Q6H
4. Inj. Monocef 1 gm IV BD
(ceftriazone)
5. Inj . Heparin 500 units I/V Q6H

12. 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 1-0-0
11.T.Pletoz 50 mg 1-0-1
(cilostazol)

13. cotn.
DAY 2
PR: 80/mts
BP: 150/90 mmHg
Chest: clear, AEBE
CVS: s1 ,s2 normal
Repeat 1-10
12. Inj.Methyl Prednisolone 1gm IV
in 500ml NS

14. cotn.
DAY 3
PR: 92/mts
BP: 140/80 mmHg
Chest: clear, AEBE
CVS: s1,s2 normal
Repeat 1-11

15. cotn
DAY 4
PR: 84/mts
BP: 140/80 mmHg
Chest: clear, AEBE
CVS: s1s2 normal
Pain decreases
Oedema decreases
afebrile
Repeat 1-11

16. 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

17. cont
DAY 6
PR: 74/mts
BP: 150/90 mm/Hg
Chest: clear, AEBE
CVS: s1s2 normal
Repeat 1-12

18. 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 1-0-0
20 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

19. PROBLEM LIST
Rheumatoid Arthritis
Leg ischemia and chronic ulcer

20. SOAP ANALYSIS
Rheumatoid Arthritis

21. 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.

22. 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.

23. 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.

24. PLAN
Aspirin 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.

25.  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.

26. ASSESMENT, PLAN AND FOLLOW UP
Date 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
inflammatio
n
Joints pain
associated
with
intermittent
fever. And
inflammation
T. Microcid
25 mg 1-0-1
T. Sazo 500
mg 1-0-1
T. Mexit 2.5
mg 1-1-1 ,
T. Folvite 5
mg 1-0-0
10.T.
Omnacortil
40 mg 1-0-0
30 mg 1-0-0
Return for
check up.

27. 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
inflammati
on
Pain
decreases
Oedema
decreases
afebrile
Repeat the
above
medications
Return for
check up.

28. 4-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce
pain and
inflammat
ion
Pain
decreases
Oedema
decreases
afebrile
Repeat the
above
medicatio
ns
Return for
check up.
5-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce
pain and
inflammat
ion
Pain
decreases
Oedema
decreases
afebrile
Repeat the
above
medicatio
ns
Return for
check up
6-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce
pain and
inflammat
ion
Relieved
discharge
with
advice
Repeat the
above
medicatio
ns
Discharge
with
advice

29. 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.

30. 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.

31.  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.