CASE PRESENTATION ON RHEUMATOID ARTHRITIS
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Transcript of CASE PRESENTATION ON RHEUMATOID ARTHRITIS
WELCOME
Presented by
Binuja.SS
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.
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
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.
FAMILY HISTORY:
No relevant family history.
No history of similar illness in the past.
HABITS:
Anorexia
Sleep decreased
Bowel and bladder habits normal
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 tenderNo hepatomegalyNo spleenomegaly
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
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
PROVISIONAL DIAGNOSIS Rheumatoid Arthritis
Leg ischemia and chronic ulcer
TREATMENT SCHEDULEDAY1
Pedel oedema and non healing ulcers over L and R legFeverJoint painCVS: 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 Q6H4. Inj. Monocef 1 gm IV BD
(ceftriazone)5. Inj . Heparin 500 units I/V Q6H
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 1-0-011.T.Pletoz 50 mg 1-0-1
(cilostazol)
cotn.DAY 2
PR: 80/mtsBP: 150/90 mmHgChest: clear, AEBECVS: s1 ,s2 normal
Repeat 1-10 12. Inj.Methyl Prednisolone 1gm IV in 500ml NS
cotn.DAY 3
PR: 92/mts
BP: 140/80 mmHg
Chest: clear, AEBE
CVS: s1,s2 normal
Repeat 1-11
cotnDAY 4
PR: 84/mtsBP: 140/80 mmHgChest: clear, AEBECVS: s1s2 normalPain decreasesOedema decreasesafebrile
Repeat 1-11
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
contDAY 6
PR: 74/mtsBP: 150/90 mm/HgChest: clear, AEBECVS: s1s2 normal
Repeat 1-12
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 1-0-020 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
PROBLEM LIST Rheumatoid Arthritis
Leg ischemia and chronic ulcer
SOAP ANALYSIS Rheumatoid Arthritis
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.
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.
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.
PLANAspirin 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.
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.
ASSESMENT, PLAN AND FOLLOW UPDate 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. Microcid25 mg 1-0-1T. Sazo 500 mg 1-0-1T. Mexit 2.5 mg 1-1-1 , T. Folvite 5 mg 1-0-0 10.T. Omnacortil40 mg 1-0-030 mg 1-0-0
Return for check up.
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 decreasesOedemadecreasesafebrile
Repeat the above medications
Return for check up.
4-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce pain and inflammation
Pain decreasesOedemadecreasesafebrile
Repeat the above medications
Return for check up.
5-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce pain and inflammation
Pain decreasesOedemadecreasesafebrile
Repeat the above medications
Return for check up
6-8-13 RA Joints pain
associated
with
intermittent
fever.
Reduce pain and inflammation
Relieved discharge withadvice
Repeat the above medications
Dischargewith advice
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.
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.
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.