70 YEAR OLD MALE WITH SYMMETRIC POLYARTHRITIS,RA AND CKD

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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.

Case history:

A 70 year old male,who used to work as Mason but stopped working since 3-4 years 

Patient gives h/o multiple joint pains since 3-4 yrs,  started in small joints of hands and feet and later progressed to ankle, knee, wrist, elbow and shoulder joints.

-It started as a swelling along with stiffness of joints and now progressed to deformity.

-This is associated with fever and  difficulty in performing daily activities. 

-Patient also complained of lower back ache , dragging type at sacral region since 2 years ,non radiating ,not associated with tingling or numbness 

 Since 6 months 

-patient c/o instability while walking/climbing stairs predominantly with right knee joint. 

-Patient  also h/o sudden onset of giving away / instability of right knee joint ,while walking or climbing stairs ,hence using stick for support 

- also complaints of  difficulty in getting up from sitting/squatting position. 

From past  1 month

-he has neck pain,non radiating , dragging type  with restriction of neck movements. 

-No  h/o tingling or numbness .

-H/o taking NSAIDS for 1 year.

-H/o pedal edema since 1 year(pitting type)

-h/oFacial puffiness(resolves spontaneously)

 

-No h/oOliguria &SOB

Not a k/c/o DM, HTN, Asthma, Epilepsy. 

General examination:

patien is conscious , coherent , cooperative

Pallor-Ab

Icterus-Ab

Cyanosis-Ab

Clubbing-Ab

vitals:

Bp-120/80mmHg

SpO2 at RA-99%

PR-88bpm

Respiratory rate-19cpm

Temperature-98. F

Systemic examination:

RS - normal vesicular breath sounds heard

CVS- S1S2 heard

          No murmurs heard 

Musculoskeletal system-

   Hands :thumb-boutinerrie deformity

                Fingers-swan neck deformity

  Joint swellings present 

    Synovial thickening at MCP, PIP joints 

    Small nodules at DIP joint 

    Tenderness at MCP, PIP joint 

    Flexion deformity of little finger both hands 

 Wrist:Joint tenderness

            Restriction of movements 

 Elbow:Subcutaneous nodules present at elbow

 Knee: crepitations are felt at Right knee 

 Ankle : Swollen joint 

              Tenderness present 

Past investigations and treatment - 

He visited multiple hospitals for above complaints ,his uric acid was always at 7-9 ,RA factor was negative.

He used febuxostat ,NSAIDs , Wysolone intermittently for.

  

Ortho refferal:

X-ray :

Investigations: