CASE PRESENTATION ON RHEUMATOID ARTHRITIS

CASE STUDY OF RA

1. WELCOME

2. CASE PRESENTATION ON RHEUMATOID ARTHRITIS Presented by B inuja.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 P I C C L E 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:15m g/ 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 4 th 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 7 th 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 inflammation 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 inflammation 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 inflammation Pain decreases Oedema decreases afebrile Repeat the above medications Return for check up. 5-8-13 RA Joints pain associated with intermittent fever. Reduce pain and inflammation Pain decreases Oedema decreases afebrile Repeat the above medications Return for check up 6-8-13 RA Joints pain associated with intermittent fever. Reduce pain and inflammation Relieved discharge with advice Repeat the above medications Discharge with advice

29. COMMENTS ON THERAPY A disease modifying antirheumatic drug should be started within the first 3 months of symptom onset. E arly introduction of DMARD results in a more favourable outcome.(As per DIPIRO Pharmacotherapeutic Approach,7 th 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.

32. THANK YOU……