1702102085 SHORT CASE

A 45 year old male patient who is a farmer by occupation , chronic alcoholic .

Presented to opd with 

History of pain & swelling at right first metatarsal joint since 5 months.

B/l ankle joint & left knee joint pain & swelling associated fever since 1 week

Low back ache since 3 days


Restriction of movement present at left knee joint and b/l ankle joint


Fever since 1 week - low grade , intermittent , decrease with medication


No h/o small joint involvement

No h/o early morning stiffness

No h/o pain/restriction of movements at UL joints 

No h/o rash

No other complaints


Past history:

No h/o DM/HTN/Asthma/Epilepsy/CAD/TB


Personal history:

Diet : mixed

Sleep : adequate

B&B : regular

Addictions : chronic alcoholic since 20 yrs


General examination:

Patient c/c/c

Pallor +

PR: 62 bpm

BP: 110/70 mmhg


Local examination:

Swelling , local rise of temp & Tenderness present at right 1st MTP joint, right ankle joint

& left knee joint.





Left lower limb




Systemic examination:

                


CVS:

Elliptical & b/l symmetrical chest

Apex beat palpable at 5th intercostal space medial to midclavicular line 

S1 , S2 heard

No murmurs


RS:

B/l air entry +, normal vesicular breath sounds


P/A:

Scaphoid 

Soft, NT

Bowel sounds present


CNS:

Conscious and alert 

NFND


INVESTIGATIONS:


X-ray left foot with ankle AP view



X-ray right foot with ankle AP view


ECG


Chest x-ray


USG abdomen:

Right kidney : decreaded size, CMD partially maintained

Grade - 2 RPD

Left kidney : normal size, CMD partially lost

Grade - 1 RPD


USG b/l knee joint:

Left knee joint mild effusion with bursitis

Right knee joint minimal effusion


Hemogram:

HB:8.3mg%

TLC:11,000

PLT:3₹.52


CUE:

Albumin: +

Sugar: nil

PC:2-4

EC:1-3

RBC:nil


RFT:

Urea:3.8mg/dl

Creatinine:2.2

U. A3.9

Na+:138

K+:4.1

Cl-:98


LFT:

TB:0.71

DB:0.21

AST:53

ALT:35

ALP:33%

TP:7.7

ALB:3.86

A/G:1.01


CRP: Positive



Provisional diagnosis:

?Gouty arthritis

Microcytic hypochromic anemia - ? IDA

CKD - ? Analgesic nephropathy/Gouty nephropathy


Treatment: 

1) Inj Tramadol 1Amp in 100ml Ns IV/SOS

2) Tab wysolone 5mg PO/OD

3) Tab Colchicine 0.5mg PO/OD

4) BP/PR/Temp/SpO2 monitoring


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