60Y MALE WITH MULTIPLE SWELLINGS SINCE 1 YEAR

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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.

13/09/2023

This is a case of 60 year old male came to medicine opd with chief complaints of

 fever since 10 days 

Multiple joint pains since 1year

B/l lower limb swelling since 1 year 

-Fever which is high grade associated with chills and rigors more during night time relieved on taking medication .

-Multiple joint pains- both hands metacarpophalangeal joints,both knee joints,both elbow joint

-JOINT RESTRICTION PRESENT

-Morning stiffness present

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

-No c/o cough,weight  loss since 6 months

-No c/o decreased urine output

-c/o b/l lower limb swelling which is pitting type till ankle since 1 year

-H/o chronic nsaid usage since 1 year as he is having joint pains

-Not a k/c/o DM, HTN, CVA, CAD ,TB ,EPILEPSY 

Surgery referral was done on 13/09/23 i/v/o left middle toe trauma and advised

Tab augumentin 1.2 mg iv BD

Tab METROGYL 500 mg iv tid

Tab pan 40 MG po od

Inj  pcm 1gm iv BD

Tab CHYMEROL FORTE po tid

Tab vit c po od

Oint t bact for L/A

Left lower limb elevation

Active ambulation

Ortho referral was done on 18/09/23 i/v/o osteomyelitis of left 3rd and 4th toe and advised tab febuxostat 40 MG po/bd

Personal history:

Diet - mixed

Band b -regular

Appetite -decreased since 1 month

Sleep -adequate

Addictions-smoked chuttas for 20 years and stopped 1 year back

Family history:

No significant family history present

GENERAL EXAMINATION:

-mild palor seen

-No Icterus

-No cyanosis 

-No lymphadenopathy

-Edema of feet present ,pitting type upto knees

-No clubbing of fingers

Vitals:

Temperature:

 Febrile - 101°F

Pulse: 82 beats per minute

Respiratory rate: —16 cycles per minute

Blood pressure: 120/70 mm of Hg

Grbs-90mg%

SYSTEMIC EXAMINATION:

Cardiovascular system:

No thrills

No murumurs

Cardiac sounds: S1, S2 present 

Respiratory system:

Bilateral airway entry present,normal vesicular breath sounds heard

Abdomen: 

shape scaphoid 

umbilicus central , inverted

no increase in local temp,no tenderness

No spleenomegaly

No hepatomegaly

BS+

Musculoskeletal system examination: tenderness 

                                                       RT.              Lt

Metacarpophalangeal joints.     Present.   Present 

Dip.                                                 Present.   Present

Pip.                                                  Present.  Present

Joint restriction present over mcp joint

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 -

Culture for wound swab-

Investigations:

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- negative

Pus cultures-  klebsiella species was identified

Xray of left foot-

 permeative lysis of distal phalanges of 3rd and 4th toe -? osteomyelitis

-Rest of the interphalangeal joints show osteoarthritis

-MTP 

USG-

Grade 2 RPD changes in Rt kidney

Grade 3 RPD changes in Lt kidney

Plan of Treatment-

Inj Augmentin 1.2 gm IV/BD

Inj Metrogyl 500 mg IV/TID

Inj Pan 40 mg IV/OD/bbf

Tab HCQ 200 mg PO/BD

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

Regular MGSO4 dressings to lt foot