50 year male with B/L knee pain and swelling of joints

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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

DAILY ROUTINE

Patient was a farmer by occupation but since 5 years he has stopped farming.He stays at home and does his daily routine.

Since one week he is not able to walk,cant lift weights and is not able to do his daily activities.

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 5 years ago,he then developed bilateral knee joint pain which was insidious in onset,gradually progressive.

Patient has been on medication but there is no complete pain relief.

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 involved

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

-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