70yrs old with joint pains
A 70 year old male,who used to work as a Mason till the age of 68 years , stopped working since 2 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)
No Oliguria and SOB
K/c/o HTN from 4 years
Not a k/c/o DM, Asthma, Epilepsy.
General examination:
Pallor-N
Icterus-N
Cyanosis-N
Clubbing-N
Bp-120/80mmHg (at present)
SpO2 at RA-99%
PR-88bpm
Respiratory rate-19cpm
Temperature-98. F
Systemic examination:
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
CVS-S1S2+,No murmurs heard
Respiratory system-BAE+,NVBS
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 refer notes:
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
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