Case Presentation on Rheumatoid athrities

Details Case presentation on Rheumatoid athrities

1. Presented by: MAKBUL HUSSAIN CHOWDHURY Pharm. D 3 rd year CASE PRESENTATION ON RHEUMATOID ARTHRITIS

2. Rheumatoid Arthritis Rheumatoid arthritis (RA) is an autoimmune disease that can cause joint pain and damage throughout your body. The joint damage that RA causes usually happens on both sides of your body.

3. Age- 30 years , Male. Weight- 75 kg. I.P NO.-19426694 DOA- 09 Feb. 2018 DOD – 14 Feb . 2018 WARD- ORTHO Patient details- Subjective

4. Patient came with C/O – Pain and swelling in small joints of fingers * 6 months. Pain in lumbar region radiating to right leg * 6 months. Morning stiffness in joints of fingers and toes for about 2 hours. Decreased grip in fingers. Difficulty in standing. No H/O DM/HTN/TB/BA etc . Reason for admission subjective contents

5. Family history – not significant Personal history – non smoker, non alcoholic , vegetarian by diet Family and Personal history -

6. Pt. calm, conscious and oriented. R/S – B/L air entry equal. No abnormality detected. CVS – S1,S2 normal. P/A – soft , non tender , non distended CNS – intact Diffused swelling present in all small inter- phalangeal and meta- carpophalangeal joints with redness of skin. No visible deformity present. On Examination-

7. Vitals Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 BP (mm Hg) 130/80 130/80 120/80 110/80 110/80 120/80 PR (/min) 76 72 74 72 72 72 RR (/min) 24 22 24 22 22 22 Temp. (˚F) Afeb. Afeb. Afeb . Afeb . Afeb . Afeb . Vital Signs :

8. Lab Investigations- objective cont Constituents Detected values Normal range Hb 13.0 13-17 gm % ESR 45 0-9/1 ST hour TLC 11600 4000-10,000 /cumm CRP Positive RA Factor Latex NEGATIVE These tests were performed in hospital laboratory on 9-10 feb.2018.

9. Constituents Detected values Normal range TSH 0.85 0.35 – 5.50 µ IU /ml S. Uric acid 6.10 3.4 – 7.0 mg % Calcium 8.30 8.0-10.5 mg/ dL CRP (quantitative) 11.70 0.0 – 6 mgm /L RA Factor (quantitative) 18.40 ˂ 14 IU/mL Lab investigations These tests were performed in some other laboratory on 19-20 jan.2018.

10. Nerve conduction tests – Neuropathy of left upper limb. (17/1/2018) Other investigations

11. Assessment Subjective Objective Pain and swelling in small joints of fingers * 6 months Pain in lumbar region radiating to right leg * 6 months Morning stiffness in joints of fingers and toes for about 2 hours Decreased grip in fingers Difficulty in standing Diffused swelling present in all small inter- phalangeal and meta- carpophalangeal joints with redness of skin ↑ ed ESR ↑ ed TLC CRP – POSITIVE RA Factor – POSITIVE

12. Assessment On the basis of subjective and objective information patient was diagnosed with Rheumatoid Arthritis with Neuropathic pain .

13. Treatment Plan

14. Drug Dose and frequency Route Start Stop Class Inj. Mecotop-G ( Gabapentin+ Methylcobalamine ) 300 mg + 1000 mcg , OD IV 9/2 10/2 Anticonvulsant & Neuro-protectant Tab. Myelin-G ( Gabapentin+ Methylcobalamine ) 300 mg + 500 mcg , BD (1-0-1) Oral 11/2 13/2 Anticonvulsant & Neuro-protectant Tab. Defkors ( Deflazacort ) 6 mg , BD (1-0-1) Oral 9/2 13/2 Corticosteroid Cap. CYRA-D ( Rabeprazole + Domperidone ) 20 mg + 30 mg , OD (1-0-0) , BBF Oral 9/2 13/2 Proton pump inhibitor & Anti-emetic Tab. Methotrexate ( Methotrexate ) 7.5 mg , Once a week Oral 9/2 DMARD Tab. ACECLOFLAM-SP ( Aceclofenac + PCM +Serratiopeptidase ) 100 mg + 325 mg + 10 mg , BD (1-0-1) Oral 9/2 13/2 Analgesic & Anti-inflammatory

15. Drug Dose and frequency Route Start Stop Class Tab. HCQ ( Hydroxychloroquine Sulphate ) 200 mg , OD (1-0-0) Oral 9/2 13/2 Anti-inflammatory Tab. Sazo ( Sulfasalazine ) 500 mg , BD (1-0-1) Oral 9/2 13/2 Sulphonamide & DMARD Cap. Oxuba ( Oxaceprol ) 200 mg , BD (1-0-1) Oral 9/2 13/2 Anti-inflammatory Tab. Revozyme Forte ( Trypsin+Bromelain+ Rutoside Trihydrate ) 96 mg + 180 mg + 200 mg , OD (0-1-0) Oral 12/2 13/2 Anti-inflammatory enzymes

16. SHORT TERM GOAL- To provide symptomatic relief from pain of joints and lumbar region pain. To reduce inflammation. LONG TERM GOAL- To prevent or control joint damage. To preserve function of joints. To decrease the mortality. To improve quality of life. Therapeutic goals

17. Liver function tests. CBC (for leucopenia ,thrombocytopenia , anemia) Blood calcium levels. Serum Albumin levels. Renal function tests. Fundus examination. Monitoring Parameters

18. BP- 120/80 mmHg PR- 74/min. RR – 22 /min. Afebrile Swelling present(↓) over interphalangeal joints and metacarpophalangeal joints. Discharged summary (14/2/2018)

19. Tab. Myelin-G 1*BD Tab. Defkors 6 mg 1*BD Cap. CYRA-D 1*OD (BBF) Tab. Methotrexate 7.5 mg 1*week Tab. HCQ 200 mg 1*OD Tab. SAZO 500 mg 1*BD Tab. Oxuba 200 mg 1*BD Tab. Revozyme 1*OD Tab. ACECLOFLAM –SP 1*BD (For 15 days ) Discharge medication-

20. Exercise regularly to relieve pain and improve activity of joints. Take adequate rest. It will help in reducing inflammation. Prolonged inactivity may lead to stiffness and loss of joint motion, as well as muscle wasting and osteoporosis. Therefore there should be an appropriate balance of rest and exercise. Avoid unnecessary stress. Patient counselling-

21. Adhere to the medication. Tab. Methotrexate is to be taken is to be taken once a week. Do not avoid symptoms like nausea , vomiting , mouth ulcers , dizziness , shortness of breath, easy bruising or bleeding etc. Do not worry ,If your skin color and urine color appears yellow orange as it is because of sulfasalazine . Do not drive or handle machinery after taking Tablet Myelin-G . Avoid prolonged exposure to sunlight and use sunscreen (SPF 15 or higher) when outdoor. Keep Tab. Defkors away from persons having Chicken pox , Measles & if you do catch them , immediately report about it to Physician. Patient counselling- (drug related )