60 YR OLD MALE WITH FEVER COUGH AND PAIN IN MULTIPLE SMALL JOINTS

A 60 yr old male came to the OPD with chief complaints of 
.Fever since 10days
.pain in multiple joints of hand from past 2 yrs
.pedal edema since 15 days
HOPI:patient was apparently asymptomatic 2 yrs back then he had multiple joint pains( both hands metacarpophalangeal joints and both knee joints.joint restriction present . morning stiffness present
c/o lower limb swelling since 1 yr pitting type till ankle
H/o trauma to left leg middle toe 1 month back
No c/o cough
No c/o decreased urine output 
H/o chronic NASID abuse since 1 yr for joint pain
Past history:N/k/c/o HTN DM TB CVA CAD Asthma epilepsy 
Family history:Not significant 
Personal History
  Diet:mixed
  Appetite:decreased
  Sleep:aquate
  Bowel irregular and bladder: normal
  No addictions 
  
General Physical Examination
  Patient is conscious coherent and cooperative
    Moderately built and moderately nourished
             No pallor,Icterus,cyanosis, clubbing,lymphadenopathy
  
Vitals
         Temperature:100 F
         Pulse rate:68beats per minute 
         Respiratory rate:18 C/minute
         BP:130/90 mm Hg
Systemic examination
     CVS:S1 S2 heard  no murmurs
     RS:BAE +
     CNS:no focal neurological deficit 
P/A
On inspection:
shape of abdomen :scaphoid
On palpation 
    Non tender no organomegaly
Musculo skeletal system:  tenderness 
                     Rt.         Lt
MCP joints   +.          +
DIP joint       +.          +
pIP joint       +.          +
Investigations
Hb:8.7gm/dl
TLC:17600cells/cumm
PCV:26.4
PLT:4.46 lakhs/cumm
TB:1.04
DB:0.24
SGOT:24
SGPT:19
Alkaline phosphate:239
Serum creat:2.5
Blood urea:68
RBS:109
Uric acid:5.8
                       Chest x ray 

ECG
provisional diagnosis:
??Rheumatoid arthritis
??CKD secondary to NASID abuse with left foot cellulitis

Treatment:
1.INJ AUGMENTIN 1.2 gm IV/BD
2.INJ METROGYL 500mg IV/TID
3.INJ PAN 40mg IV/OD
4.TAB HCQ PO/BD
5.TAB DOLO 650mg PO/TID
6.TAB LASIX 20mg PO/BD
7.INJ NEOMOL IV/SOS
8.TAB.NODOSIS PO/BD









      

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