Case Presentation On

Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II
By :- Teena
1412818
Pharm.D 3rd yr
 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
 Physical Investigation
9 10 11 12 13 14 15 16 17 18 19
Vital feb feb feb feb feb feb feb feb feb feb feb
s
BP(mm 160/ 130/ 140/9 130/9 140/ 160/ 140/ 140/ 130/ 150/ 160/
/Hg) 90 80 0 0 80 100 80 90 90 90 90

Pulse 90 80 124 100 120 100 90 120 112 104 128

Rate
(/min)
Resp 18 18 18 18 16 18 18 18 20 18 18
Rate
(/min)
Temp Afeb. Afeb. Afeb. Afeb. Afeb. Afeb. Afeb. Afeb Afeb Afeb Afeb
(F)

FBS - - 143 163 107 135 97 59 93 80 71

 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%

0 – 20mm/1st hr
ESR 40
HB 10.8 12 – 15gm %

Platelet count 2.3 1.5 – 4.5 lac/ cumm

TLC 5700 4000 – 10000 / cumm

LFT 0.72 0.20 – 1.00 mg/dl
Bilirubin Total
0.24 0.10 – 0.30 mg/dl
Bilirubin Direct
SGOT 70 5 – 40 IU/L

SGPT 90 5 – 35 IU/L

Alkaline Phosphatase 181 5 – 112 IU/L

RFT 44.38 15 – 40 mg/dl

Urea
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

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
 Specific Test

 USG Abdomen
Impression : fatty liver with hepatomegaly
 COLOR DOPPLER TEST
Left leg shows atherosclerotic changes in
lower limb arteries .
 HBA1C : 8.7%
Diagnosis
Lt Foot Gangrene
+
Drug induced Cushing syndrome
+
Rheumatoid arthritis
+
DM II
 Treatment
DRUGS + API Dose + Date Date Category Frequency
Route of of
Start Stop
Tab. HCQS 200mg 9/02 19/02 Anti BD
(hydroxychloroquin oral Rheumatoid
e) agent
Tab. Methotrexate 7.5mg 9/02 -- Anti Once a
Oral Rheumatoid week
agent
Cap. Cyra-D 50mg 9/02 19/02 PPI+ OD
(Rabeprazole + Oral antiemetics
Domperidone)
Cap. A to Z 9/02 19/02 Multivitamin OD
Oral

Tab. Folvite 5 mg 9/02 19/02 supplement OD

(Folic acid Oral
)
DRUGS + API Dose + Date Date Category Frequency
Route of of
Start Stop
Tab. Vorth 50mg 9/02 16/02 Analgesic OD
(Tapentadol) Oral
Tab. Shelcal 500mg 9/02 19/02 Supplement OD
(Calcium + vit D) Oral
Tab. Dolo 650mg 12/02 13/02 Anti pyretic + BD
( PCM) Oral Anlagesic

Tab. Ecospirin AV 12/02 12/02 Anti platelet HS

( Aspirin + oral + Anti
Atorvastatin ) Hyperlipide
mic agent

Tab .Metformin 500mg 11/02 19/02 Oral OD

Oral Hypoglycemi
c agent
 DRUGS + API Dose + Date of Date of Category Freque
Route Start Stop ncy
Tab. Melson 16mg 13/02 19/02 Corticosteroid BD
(predinisolone) Oral
Tab. Acuclav ( 625 mg 14/02 13/03 Anti biotic OD
Augmentin) Oral
Tab . 40mg 14/02 19/02 Anti OD
Telmisartan oral hypertensive
Tab . 19/02 17/02 Anti OD
Carvedilol* Oral hypertensive

 On 14 feb 2015, there was a surgery call and 3rd

toe of left foot is removed as there is 80% sensory
loss
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
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
ASSESSMENT
• The patient on basis of subjective and
objective information was diagnosed with
Lt Foot Gangrene + Drug induced Cushing
syndrome + Rheumatoid arthritis + DM II
PLAN
• SHORT TERM GOALS • LONG TERM GOALS
 Relieve symptoms  Delaying or halting the
progression of RA
 Controlling the disease
from getting more
complicated
 Controlling sudden
elevation in blood
glucose level.
 Patient Counselling
 Adhere to the medication
 Periodic checkup.
 Mild exercise to improve the range of joint
motion.
 Take adequate rest .
 Physiotherapy recommended .
 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.