58 M with acute asymmetrical polyarthritis

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 COURSE OF LIFE EVENTS:PERSONAL HISTORy

58 male hailing from narayanapuram ,choutuppal,

born in 1964

A 6 years got seizures, 

from 7th class he got one sided headache associated with bilious vomiting ( stopped at 32 years)

studied until 10th class ,kabaddi player long jump(13feet) , 

he started smoking,


From 1990 he started consuming alcohol,1994 he got job as a  supervisor in mumbai , got addicted to gambling and alcohol 75ml per day for 15 years , usually smokes 30 cigarrette per day for 15 years , Rich person at those times, usually takes high protein diet.  admitted in hospital for cold with  headache done spinal injection( lumbar puncture ? meningitis?)for 20 days . He quit smoking and alcohol there after .He quit job in mumbai due to some brother disputes and lost his money .He does real estate and also upasarpanch has anger episodes

in 2000s ,he got swelling at 1st MTP with severe pain , swelling developed in a day  , joined in a hospital for 10 days but no diagnosis , then after the swelling subsided another leg got swelling .sometimes both at once usually aggravates after heavy dinner ( mutton ,fishes, tamarind, curd) could not sleep that day. involved all other limbs ankle, wrist , elbows , left shoulder , severely affected on right side for 23 years , cannot do work as before sudden loss of consciousness but didnt fall, for 3 times   hypertensive (140/80mmhgsince 2 years on medication( found out giddiness with sweating)

intermittent pedal edema insidious onset, gradually progressive , pitting type not associated with pain ,In night upto ankle aggravated on tamarind and curd relieved by it's own  or medication. burning micturition since 1 and half month,increased frequency of urine,4- 5 times at night.








GENERAL EXAMINATION 

NO PICCLE 

HEAD TO TOE

skin - erythema present on left hand, no

features suggestive of rheumatology palpable purpura, erythema nodosum,no ulcers, no rash,no keratoderma blenorrhagica , mucosal ulcers,dryness of skin or thickened skin,pyoderma gangrenosim, photosensitivity,palmer erythema, digital gangrene, salt and pepper appearence,lived reticularis,raynauds,screlodactyly

nails - no clubbing,no pitting and onycholysis, no splinter hemorrhages

oral cavity 

mucous membrane

eye- dryness ,scleritis/episcleritis,,iridocyclitis,conjuctivitis,scleromalacia perforans, tenosynovitis of superior oblique

LOCOMOTOR SYSTEM EXAMINATION 

GALS

GAIT 

ARMS 

LEGS 

SPINE 

JOINT EXAMINATION:

1)PIP and DIP

2)MCP

3)carpometacarpal joint of thumb

4) wrist joint

5)ELBOW HOINT

6) sHOULDER JOINT

7) A cromioclavicular

8) Sternoclavicular

9) Temporomandibular 

10) HIP JOINT 

11) Knee joint

12) Sub talar joint 

13) Small joints, midtarsal mtp, interphalyngeal jlint

wrist joint of left hand 

Inspection :swelling present

PALPATION:tenderness, local raise of temperature

crepitus cannot be demonstrated

synovial thickening  absent

Range of movements - active - ,restrictedpainful

passive ,restricted ,painful

ANKLE JOINT

inspection normal 

palpation 

fine crepitus can be felt at bare area

no synovial thickening 

range of movements 

active - restricted painful

passive - same

Examination of SPINE:

cervical spine: Normal

Rotation 

flexion

extension 

lateral bending

THORACOLUMBAR  SPINE NORMAL

Flexion 

Extension

lateral bending

Rotation 

schobers

straight leg raising test

Sacroiliac joint 

Direct pressure 

Patrick's test

Gaenslen test

LIgaments 

tendoachiliis ,olecranon no thickening ( no  enthesitis)

Squeeze test negative

ACUTE ASYMMETRICAL inflammatory polyarthritis without deformities and without spine involvement with systemic involvement ( renal stones). I would like to consider GOUT

My Differentials:

Gonococcal arthritis( fever)

hereditary hemochromatosis ( chondrocalcinosis)

pseudogout 

undifferentiated poly arthtitis

29/5/23

Ward gm -4AMC Bed 1

Dr.Zain( sr)

Dr.Venkat Sai (pgy2)

Dr.Nithin gautham (pgy1)

Dr.Tejasri(intern)

Dr.Pavithra(intern)

58 year old male

S

 Decreased swelling 85% and pain 80% of right wrist and 4 and 5th mcp joint


O:

Patient is c/c/c

Temp;afebrile

BP:120/80

Pr:94 BPM

Rr:20cpm



 A 

Acute asymmetrical inflammatory polyarthritis(?gout)


              27/5.   28/5.  29/5

Creat: 3.0.      2.7        2.7

 UA:    9.1.      

 25/5

hb - 11.1

TLC -11200

Pcv:32.9

RBC:4.59

Plc:2.9



O

Patient is c/c/c

Temp:- 98

PR- 98bpm

RR - 30cpm

BP-  160/90mmHg

GRBS- 147mg%

I/0-


CVS- S1s2present, no murmurs heard

RS-B/L air entry present 

       NVBS present

PA- soft,non tender.

CNS - NFND






P:

1.T.amlodipibe 5mg po/od

2.T.tamsulosin-d 0.4mg po/of

3.T.pan 40mg po/of

4.T.wysolone 10mg po/od

5.Tab.NODOSIS 500mg PO/bd

6.T.ultracet 1/2 po/bd

7.T.febuxostat 40mg po/bd

8. Vitals monitoring 4 hrly


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