A 60 yr old female with polyarthritis and bilateral pedal edema



 Hello everyone! I’m Rohini , an intern posted in General medicine department. 


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Here is a case i have seen:

A 60 yr old women presented to causality with

Complaints of Bilateral knee pain(aggravated) since

                           5days           

                       Bilateral pedal edema since 5 days 

She worked as a farmer for 35 years but from past 10 years she stopped going to work due to pain in both knee joints.

Patient was apparently alright 10 years back then she had h/o fever which lasted for about 3 to 4 days and subsided on taking paracetamol prescribed by local doctor. After that she felt pain in bilateral ankle joints which is associated with swelling for which she used medications ( no proper record about medication) which gave her symptomatic relief.

Then after 2 months , gradually it started involving her knees, shoulders, elbow, wrist . The pattern of involvement couldn’t be properly explained by the patient.and she even noticed deformity ( hallux varus type) of her right great toe.



Patient complained of Early morning stiffness which lasts for about 1 hour and gets relieved with work.

She was using on and off pain medications since 10 years 

Patient went to multiple hospitals and used different medications (no proper records)

Patient complained of back pain 5 years ago and used Lumbar sacral belt for 2 months ( prescribed by local doctor).it got subsided completely .

One year back , she used to walk normally.and then she underwent Right Total knee replacement surgery and left  TKR surgery  was delayed due to covid pandemic.After 2months she started walking with help of stick. Since then she is walking with stick. And from 15days she is not able to walk due to pain.


Then 10 days back she developed fever for which they visited a RMP and got treatment for it. After 2 days they gave history of slipping while walking in the house when they noticed swelling of right lower limb and next day swelling of left lower limb. They got x ray done outside which came out to be normal.Then they visited a local hospital as she started having shortness of breath grade 3. At that hospital they were asked to get HRCT and covid swab test to get admitted. After 3 days HRCT report came out as corads 2 and swab came out be negative. With those reports when they visited the hospital, she was found out to be having atrial fibrillation and was treated for it. They were then refered to another hospital for better management. In that second hospital in view of decreased urine output she was put for peritoneal dialysis(2 sessions)(as per the history given by patient and her attenders). Due to financial issues, they got discharged in that hospital and came for admission in our hospital.

She came to our hospital with complaints of Bilateral knee pain which was aggravated since 5 days which is associated with swelling in the both lower limbs.and Bilateral pedal oedema since 5 days (Pitting type up to knee)

 Not a know case of  DM,HTN,Thyroid disorder, TB

Patient developed bilateral lower limb cellulites 5 days back and also pressure necrotic patch on lower 1/3 rd posterior aspect of left leg for Which general surgery referral was taken.

Left lower limb arterial and venous doppler was done which showed:








Orthopaedic referral was taken in view of left knee swelling and pain.  

                   X-ray of left knee:



             Usg of left knee joint:



And adviced synovial fluid aspiration -

As synovial fluid  aspirated was minimal . It was not sufficient enough for microbiological study.



•General examination : 

Patient is conscious,coherent and cooperative. Oriented to time and place. Heavily built.

Pallor- present (mild)

Icterus- Absent

No cyanosis,clubbing, lymphadenopathy 

Vitals: temp- afebrile 

           BP- 130/70 mmhg

           PR-96bpm

• CVS Examination: 

Inspection-

Shape of chest-bilaterally symmetrical

Trachea-central in position

Jvp -raised


Apical impulse couldn't be seen.

Precordial and epigastric pulsations *absent

No visible scars,sinuses,engorged veins* 

Palpation-

Apexbeat- couldn't be appreciated as pt is obese .

Parasternal heave,grade1 ,over left parasternal line

No palpable thrill ,no tenderness

Auscultation-

S1,s2 heard in pulmonary,mitral,tricuspid areas

Nomurmurs

•Respiratory Examination:

Normal vesicular breath sounds, 

Bilateral air entry present 

Trachea - central

Wheeze - absent

Crepts + bilaterally in isa ,iaa,inter scapular and mammary areas

Per Abdomen: soft , non tender 

CNS : No FAD

• joint Examination:

                  Tenderness             Restriction of movement 

               Lt          Rt                  Lt              Rt 

TMJ        -                -                  -               -

Shoulder:-              -                   -               -

Elbow     -                -                    -            -

Wrist       +            +                 +              +

MCP       -               -                   -              -

IPJ

Distal      -            -                      -               -

Proximal -              -                   +               +

Hip             -           -                 -                 -

Knee          +            +               +               +

Ankle         +             +              +              +

MTP           +             +             +              -

Intertarsal.    +            +               +            +













• EULAR criteria :

Joint distribution:

> 10 joints ( atleast one small joint) : score of 5

Serology: RA factor negative: 0

Symptoms duration:

> 6 weeks: score of 1

Acute phase reactants:score of 1 

Crp negative 

Esr raised  

Total: 7 


• Investigations:

                    Outside hospital reports:

ECG showing irregular RR interval with absent P waves suggestive of atrial fibrillation 















               Day1           Day2         Day3       Day4

Total counts  :   21,500       29,500      28,700     32,600

Sr.Creatinine:     3                  3.5            3              2.9

Blood Urea :       56                86            119           58

Total bilirubin :   5.2              6.1            6.6           7.7

Direct bilirubin:   2.6               3.1           4.5            4

ALP                :     463             239         182           190

                    

                          In our hospital: 

  •On the day of admission:


Chest x-ray:









Blood group: O positive 
Urinary chloride:313 mmol/L
Spot urinary potassium: 12.8
Spot urine sodium: 279 mmol/L
Spot urine protein/creatinine ratio:0.67
FBS: 92mg/dl

Usg abdomen:





•Day1:



2d echo:





C-reactive protein- negative 
ESR-130
Blood urea - 30 mg/dl

•Day2:

She complained of pain in Left knee 
On examination:
Patient is conscious and coherent 
Vitals:
Temp-Afebrile 
PR - 98/m
BP - 110/80 mmHg 
CVS - S1S2 +, no murmurs
RS - BAE + , Fine crepts + @ B/L infra scapular region
P/A - soft, non tender, passing flatus 
CNS - HMF intact 

TLC - 18500 cells/cumm
Hb - 8.5 gm/dl 
Grbs- 124mg/dl
Urea - 30
Sr creat- 0.9 

Blood culture: no growth 
Urine culture:E.coli isolated 
Rheumatoid factor- Negative 






X-ray of both wrist : 



Day3:

She complained of pain in Left knee 
Patient is subjectively feeling better, sitting comfortably
Stools not passed, passing flatus

On examination:
Patient is conscious and coherent 
Urine I/O : 1650/2250
Grbs:126mg/dl
Vitals:
Temp-Afebrile 
PR - 98/m
BP - 110/80 mmHg 
CVS - S1S2 +, no murmurs
RS - BAE + , Fine crepts + @ B/L infra scapular region
P/A - soft, non tender 
CNS - HMF intact 


Today
TLC -  14000cells/cumm
Hb -  8.8gm/dl



  • Day 4:

C/o fever yesterday night.. 101F subsided on tepid sponging
Pain in left knee

O/E pt conscious, coherent,oriented to time place person
Febrile temp:100.9F
Grbs:128mg/dl
Urine I/0 : 1800/1350
PR: 107bpm
BP: 120/80
CVS: s1 s2+, no murmurs
RS:BAE+, B/L crepts +in IAA, ISA (R>L) 
P/A:soft, NT
CNS:no FND

Blood urea:2.7
Sr creat:0.9

 
Fever charting from the day of admission:







TREATMENT: 

Inj piptaz 2.25 gms / iv / tid 
Inj pantop 40 mg iv od 
Inj zofer 4mg iv bd 
Inj optineuron 1 amp in 100ml ns iv od
Inj lasix 20mg iv bd if sbp > 110 mmhg
Tab doxycycline 100 mg / po / bd 
Protein x powder 2tsp in 100 ml milk 
Inj metrogyl 100ml iv tid 
Inj tramadol 1 amp in 100 ml ns / iv / bd 
Syp duphalac 15 ml bd 
Soft oral diet
Adviced air/water bed,frequent change of posture, b/l lower limb elevation


DIAGNOSIS ?























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