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Case Presentation On
Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II
By :- Teena
1412818
P...
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 & i...
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/...
Laboratory Investigation
Constituents Detected values Normal Range
DLC
Polymorphs 64 40 – 75%
Lymphocytes 33 20 – 40%
Eosi...
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...
URINE CULTURE
• Vol – 40ml
• Color – pale yellow
• Urine Albumin – NIL
• Urine sugar fasting – NIL
• Pus cell – 4-5 HPF
• ...
Specific Test
 USG Abdomen
Impression : fatty liver with hepatomegaly
 COLOR DOPPLER TEST
Left leg shows atherosclerotic...
Diagnosis
Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II
Treatment
DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequency
Tab. HCQS
(hydroxychloroquin
e )
200mg
or...
DRUGS + API Dose +
Route
Date
of
Start
Date
of
Stop
Category Frequency
Tab. Vorth
(Tapentadol)
50mg
Oral
9/02 16/02 Analge...
DRUGS + API Dose +
Route
Date of
Start
Date of
Stop
Category Freque
ncy
Tab. Melson
(predinisolone)
16mg
Oral
13/02 19/02 ...
SOAP NOTE
• SUBJECTIVE
• Patient came with complaints of
 pain in B/L lower limbs & involves all small &
large joints.
 ...
OBJECTIVE
• To correct the abnormal values of :-
 Monocytes - 01
 ESR - 40
 HB - 10.8
 SGOT - 70
 SGPT - 90
 Alkalin...
ASSESSMENT
• The patient on basis of subjective and
objective information was diagnosed with
Lt Foot Gangrene + Drug induc...
PLAN
• SHORT TERM GOALS
 Relieve symptoms
• LONG TERM GOALS
 Delaying or halting the
progression of RA
 Controlling the...
Patient Counselling
 Adhere to the medication
 Periodic checkup.
 Mild exercise to improve the range of joint
motion.
...
Conclusion
• Clinical features are suggestive of steroidal
toxicity.
• Melson being a corticosteroid is given in lower
dos...
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Case presentation on RA

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patient case presentation on rheumatoid arthritis

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Case presentation on RA

  1. 1. Case Presentation On Lt Foot Gangrene + Drug induced Cushing syndrome + Rheumatoid arthritis + DM II By :- Teena 1412818 Pharm.D 3rd yr
  2. 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. 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. 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. 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. 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. 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. 8. Diagnosis Lt Foot Gangrene + Drug induced Cushing syndrome + Rheumatoid arthritis + DM II
  9. 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. 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. 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. 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. 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. 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. 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. 16. Patient Counselling  Adhere to the medication  Periodic checkup.  Mild exercise to improve the range of joint motion.  Take adequate rest .  Physiotherapy recommended .
  17. 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.

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