A 70YEAR OLD MALE WITH SYMMETRIC POLYARTHRITIS, EROSIVE RA WITH OA, CKD SECONDARY TO ANALGESIC ABUSE

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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.

A 70 year old male,who used to work as a Mason till the age of 65 years , stopped working since 5 years because of joint pains and swelling. 

1) Patient gives h/o multiple joint pains since 3-4 yrs, initially started in small joints of hands and feet and later progressed to involve 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 

2) Since 6 months -patient c/o instability while walking/climbing stairs predominantly with right knee joint. 

Patient  also c/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. 

3) Since 1 month -c/o neck pain,non radiating , dragging type  with restriction of neck movements. 

No tingling or numbness .

H/o using NSAIDS for 1 yr. 

H/o pedal edema since 1 yr(pitting type)

Facial puffiness+(resolves spontaneously) 

Oliguria -

SOB-

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

General examination:

Pallor-N

Icterus-N

Cyanosis-N

Clubbing-N

Bp-120/80mmHg

SpO2 at RA-99%

PR-88bpm

Respiratory rate-19cpm

Temperature-98. F

Systemic examination:

CVS-S1S2+,No murmurs heard 

Respiratory system-BAE+,NVBS

Musculoskeletal system-

   Hands :thumb-boutinerrie deformity

   Fingers:swan neck deformity

  Joint swellings +

    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 + at elbow

 Knee: crepitations are felt at Right knee 

 Ankle : Swollen joint 

              Tenderness+

Schobers -4 cm increase 

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.

Temperature charting:

Ortho refer notes:

X ray :

Investigations :

slide picture of FNAC of rheumatoid nodule :

Provisional Diagnosis- SYMMETRIC POLYARTHRITIS

 EROSIVE RHEUMATOID ARTHRITIS WITH OSTEOARTHRITIS

CKD SECONDARY TO ANALGESIC ABUSE. 

Treatment:

 

Soap notes:21/10/21:

S- pt is c/c/c

     Pain of left arm especially at left elbow joint. 

Objective:

Pt is  conscious

Afebrile

PR:82 bpm

BP: 110/70 mmHg

CVS: S1, S2 heard

RS: BAE+, NVBS heard

P/A: soft ,non tender ,bowel sounds present

CNS: NFND

Tone : normal b/l

 ASSESSMENT-

 SYMMETRIC POLYARTHRITIS

 EROSIVE RHEUMATOID ARTHRITIS WITH OSTEOARTHRITIS

CKD SECONDARY TO ANALGESIC ABUSE. 

  Plan of care:

  1.TAB WYSLONE 5mg/PO/OD

  2.TAB ULTRACET PO/QID

  3.TAB METHOTREXATE 7.5mg-WEEKLY ONCE 

  4.TAB FOLVITE 5mg/PO/OD

 Soap notes :22/10/21

 S- pt is c/c/c

     Pain at left elbow joint 

Objective:

Pt is  conscious

Afebrile

PR:82 bpm

BP: 110/70 mmHg

CVS: S1, S2 heard

RS: BAE+, NVBS heard

P/A: soft ,non tender ,bowel sounds present

CNS: NFND

Tone : normal b/l

 ASSESSMENT-

 SYMMETRIC POLYARTHRITIS

 EROSIVE RHEUMATOID ARTHRITIS WITH OSTEOARTHRITIS

CKD SECONDARY TO ANALGESIC ABUSE. 

  Plan of care:

  1.TAB WYSLONE 5mg/PO/OD

  2.TAB ULTRACET PO/QID

  3.TAB METHOTREXATE 7.5mg-WEEKLY ONCE 

  4.TAB FOLVITE 5mg/PO/OD

  5.TAB GABAPENTIN 100mg/H/S

  6.TAB NEUROKIND LC H/S