A 50 year old male came with complaints of bilateral knee pain and swelling since 7 days
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CHIEF COMPLAINTS
A 50 year old male,farmer by occupation came with the chief complaints of
-Bilateral knee joint pain since 7 days
-Swelling of the knee and ankle joint since 6 days
ROUTINE
The patient, a 50-year-old male, used to work as a farmer but stopped 5 years ago. He currently stays at home and follows his regular daily routine. However, for the past week, he has been experiencing difficulty walking, unable to lift weights, and unable to carry out his usual activities.
HISTORY OF PRESENTING ILLNESS
The patient was without any symptoms five years ago, but later developed bilateral knee joint pain that had a gradual and insidious onset. The pain progressively worsened over time. Despite being on medication, the patient did not experience complete relief from the pain.
In terms of the hands, the pain initially started in the wrist, accompanied by swelling and limited flexion at the metacarpophalangeal joint. After 1-2 days, the pain migrated to the elbow, causing incomplete flexion and swelling. Subsequently, the pain moved to the shoulder, leading to difficulties in lifting and abducting the shoulder. This pattern of pain and involvement alternated between the hands, meaning that when one hand was affected, the other remained unaffected.
Regarding the legs, the pain began in the ankle joint with swelling lasting for 1-2 days. Afterward, the pain progressed to the knee, causing difficulty in bearing weight and necessitating the use of a stick or support while walking. Swelling was also present in the knee. Eventually, the pain migrated to the hip joint. Similar to the hands, the pain in the legs was asymmetric, with only one leg being affected while the other remained unaffected.
In terms of the hands, the pain initially started in the wrist, accompanied by swelling and limited flexion at the metacarpophalangeal joint. After 1-2 days, the pain migrated to the elbow, causing incomplete flexion and swelling. Subsequently, the pain moved to the shoulder, leading to difficulties in lifting and abducting the shoulder. This pattern of pain and involvement alternated between the hands, meaning that when one hand was affected, the other remained unaffected.
Regarding the legs, the pain began in the ankle joint with swelling lasting for 1-2 days. Afterward, the pain progressed to the knee, causing difficulty in bearing weight and necessitating the use of a stick or support while walking. Swelling was also present in the knee. Eventually, the pain migrated to the hip joint. Similar to the hands, the pain in the legs was asymmetric, with only one leg being affected while the other remained unaffected.
No C/O Diarrhoea & Vomitings
-No C/O Shortness of Breath , Palpitations , Orthopnea,PND
PAST HISTORY
Not a known case of DM, HTN ,TB , Epilepsy , Asthma
FAMILY HISTORY
No similar complaints in the family.
PERSONAL HISTORY
Patient used to consume toddy 2-3 times a week (5-6 years back) and has completely stopped drinking now.
Appetite:Decreased
Food : mixed (since 3-4 years back stopped consuming chicken & meat)
Bowl & Bladder movements: Normal
GENERAL EXAMINATION
No Icterus , Cyanosis , Clubbing ,Lmphadenopathy.
PALLOR present
Vitals:
Temp - afebrile
BP - 100/60 mm hg
PR - 82 bpm.
RR - 19 cpm
spo2 -100
GRBS - 158 mg/dl
CVS - S1, S2 heard
RS - bae present
P/A - soft , not tender
CNS - NAD
EXAMINATION OF JOINTS
Wrist joint : Partial Movement of flexion and extension approximately 30-45 degrees
Swelling + at Wrist joint
Fingers : unable to completely flex phalanges, Stifness +
Knee & ankle joint : Unable to flex completely , but can flex upto 30 degrees
Swelling + , Stiffness +
Elbow : can flex and Extend Normally
Shoulder : can lift shoulders above the head but not 180 degrees at shoulder Joint
INVESTIGATIONS
HAEMOGRAM
Haemoglobin - 4.6
Total Count - 10,200 cells / cumm
Rbc - 1.76 million / cumm
Platelet Count - 2.40 lakhs
Reticulocyte Count - 0.8 %
ESR - 150
RA Factor - Negative
Peripheral Smear :
RBC Normocytic normochromic with few microcytes tear drop cells pencil forms
WBC With in normal limits absolute neutrophilia
PLATELET Adequate
Synovial Fluid
Sugar - 140 mg/dl ( 60-100 mg/dl)
Protein - 4.2 mg/dl ( 10-45 mg/dl )
Uric Acid - 10.7 mg/dl ( 10.7 mg/dl )
Synovial Fluid Cell Count
Colour - Yellowish
Appearance - Cloudy
Total Count - 29000 cells
Monocytes - Nil
Neutrophils - 95 %
Lymphocytes - 05 %
RBC - Nil
LDH - 240 IU/L
RFT
Blood Urea - 56
S Creatinine - 1.6
S Uric Acid -
Na - 130
K - 3.7
Cl - 92
CRP - Negative
ApTT - 31 sec
PT - 15 sec
INR - 1.11
Blood Group - B Positive
Synovial fluid cytology
X-RAYS
ECG
PROVISIONAL DIAGNOSIS
Anaemia Under Evaluation with ? Iron Deficiency Anemia with Rheumatoid Arthritis ( seronegative ) with Hyperurecemia
TREATMENT
-Inj Monocef 1 gm IV / BD
-TabMethotrexate 7.5 mg / PO Weekly Once
-Tab Folvite 5 mg / PO weekly Once
-TabPrednisolone 10 mg / PO / OD
-Tab Colchicine 0.5 mg PO/BD
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