60/M c/o fever since 10 days and multiple joint pains since 1 yr

 12/09/2023

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N Joshua Paul, Intern

Pt c/o fever since 10 days which is high grade and is relieved on taking medication and is associated with chills and rigours which is more during nights 

C/o multiple joint pains (both hands metacarpophalangeal joints + both knee joints + both elbow joints) since 1 yr

Joint restriction present 

Morning stiffness present 

H/o trauma to left leg in the middle toe 1 month back

No c/o cough 

C/o weight loss since 6 months 

C/o decreased urine output

C/o lower limb swelling since 1 year pitting type till ankle

H/o chronic NSAID’s abuse since 1 yr for joint pains

N/k/c/o Htn dm tb asthma cva cad

Perosnal history-

Diet - Non veg

Appetite-decreased since 1 month

Bowel movements- Regular

Sleep - Adequate 

Addictions- smoked chutas 1 pack for 20 yrs stopped 1 yr back

No significant family history 

GENERAL EXAMINATION-

Pt is c/c//c

Pallor - Mild

Icterus - No

Clubbing - Yes

Cyanosis- No

Lymphadenopathy- No

Edema - b/l pitting upto knees

Temp - 101 F

PR - 78 bpm

BP -120/70 mmhg

Grbs - 90 mgdl

CVS - S1 S 2 + 

RS - NVBS

P/A - Soft and NT

CNS - NFND

GAIT - Slow

Joint tenderness :  R    L

MCP joints            +     + ( joint restriction present)

DIP                       +       +

PIP                         +       +

Provisional Diagnosis:

?Rheumatoid Arthritis with ? Ckd with lt foot cellulitis

INVESTIGATIONS-

Hb - 8.7 gmdl

Plt - 4.46 

Tlc - 17600

Rbs - 109 mgdl

Blood urea - 68 mgdl

Urine albumin - ++

Crp - 1.2 mgdl - Positive 

Esr -

RA - Negative

Sr creat - 2.5

Na - 135

K - 3.7

Cl - 104

Ca - 1.30

Blood cultures-

Urine cultures-

Uric Acid -

Xray-

ECG-

USG-

Grade 2 RPD changes in Rt kidney

Grade 3 RPD changes in Lt kidney

Plan of Treatment-

Tab Dolo 650 mg po/tid

Inj Neomol 1 gm IV/SOS ( if temp >101F)

Tab lasix 40 mg po/bd

Tab mvt po/od

Tab ultracet po/bd

Tab nodosis po/bd

Tab shelcal ct po/od