50yr old male with complaints of B/L knee pain

50 yr Male Farmer By Occupation  Came to Casualty With Cheif Complaints of Pain both knees since 6 days


HOPI :-

Patient Was Apparently Asymptomatic 4 years Back , Then He Developed  Knee joint Pains,bilateral ,which is Insidious In Onset, Gradually Progressive over years,and similar complaints On & off ,went to Rural Community Practitioner And Given Medicine and got relived.
 The Patient Had Been Taking pain management Medication whenever he has Joint Pains,Swelling was also present at the knee and Ankle joints during during Pain whenever he gets pain. The patient was able to do his Routine farming Activities for 2 years .

Since 2 years the patient stopped  doing  farming works and used to stay at home and was able to take care of his daily activities. 
Aggravated during walking and relived with rest and also with medication.
 Pain was not completely relieved On taking medication but patient used to feel better.
Usually pain is migratory type,unilateral and no involvement of small joints.
The pain was aggravated since 1 week and the patient was unable to walk , bear weight , take care of himself and was admitted in our Hospital , Diagnosed with Hyperuricemia & Dimorphic Anemia .

In Hands : Pain Initially Starts In the wrist , swelling apears ( flexion occurs at metacarpal-phalanges joint ) for 1-2 days , and pain Migrates to the elbow ( Unable to Flex completely , Swelling + ) for 2 days and then pain Migrates to shoulder ( unable to lift, abduct the Shoulder). and then the other hand involves 

Pain Is Assymetrical ( when one hand is involves the other is not involved )

In Legs : pain initially gets started in the ankle joint ( Swelling + , duration 1-2 days ) and pain Migrates to knee ( unable to bear weights , walks with the help of stick/ support , swelling + , duration 1-2 days ) and then the pain Migrates to the Hip joint 

Pain Is Assymetrical ( when one leg is involves the other is not involved )


No C/O Diarrhoea & Vomiting

No C/O Shortness of Breath , Palpitations , Ornthopnea ,PND

Not a Known Case of DM, HTN ,TB , Epilepsy , Asthma

No Similar Complaints in the Past

Family History : 
No Similar Complaints In the family

Personal History :
1) Alcohol : Used to consume Toddy twice a week 6-7 years Back .Now Completely Stopped Consuming Alcohol

Appetite Decreased
Bowl & Bladder movements Normal
Food : mixed , since 3-4 years back stopped consuming chicken & meat

GENERAL EXAMINATION

NO Icterus , Cyanosis , Clubbing ,lymphadenopathy.

PALLOR +

Vitals 
Temp - afebrile
BP - 100/60 mm hg 
PR - 82 bpm. 
RR - 19 cpm 
spo2 100 @RA 
GRBS - 158 mg/dl @ 8 am
CVS - S1, S2 heard 
RS - bae present 
P/A - soft , tender , Guarding Present
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.

During pain unable to lift the bucket









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
platelets Adequate

Synovial Fluid analysis:

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


Renal function tests:

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












PROVISONAL DIAGNOSIS
Anaemia Under Evaluation with ? Iron Deficiency Anemia with Rheumatoid Arthritis ( seronegative ) with Hyperuricemia


Treatment 
1) Inj Monocef 1 gm IV / BD
2) Tab Methotrexate 7.5 mg / PO Weekly Once 
3) Tab Folvite 5 mg / PO weekly Once
4) Tab Prednisolone 10 mg / PO / OD
5) Tab Colchicine 0.5 mg PO/BD

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