ANEMIA SECONDARY TO IRON DEFICIENCY SERO NEGATIVE . RHEUMATOID ARTHRITIS ? WITH CHRONIC KIDNEY DISEASE ? WITH CHOLILITHIASIS.

This is an online e log book to discuss our patient’s de- identified health data shared after taking his/her/guardian’s signed informed consent. Here we discuss our individual patient’s problems through series of inputs from available global online community of experts with an aim to solve those patient’s clinical problems with collective current best evidence based inputs. This e-log book reflects my patient centered online portfolio and your valuable inputs on the comments is welcome.”

50 years old male  resident of nalgonda who is farmer came to the hospital with the complaints of 

CHIEF COMPLAINTS :
C/o Decreased urine out put since 4 months
C/o SOB on exertion since 1 month
C/o Decreased appetite since 1 month
C/o Bilateral knee pain ,since 4 years 
         Shoulder joint pain since 4 years
C/o Bilateral pedal edema(pitting type) since 1 year


HOPI: patient was apparently a symptomatic four years back then he developed bilateral Knee joint pain (insidious in onset gradually progressive)On and off, went to rural community practitioner and given medicine, the patient have been taking pain management medication when he has joint pain. 

Swelling was also present at the knee and ankle joint during pain. The patient was able to do his routine farming activities for two years.

Since two years the patient stopped doing farming work and used to stay at home and was able to take care of his own.

When patient has pain he used to take rest and on severe pain patient used to take medication given by rural community practitioner.

Pain was not completely relieved on taking medication but patient used to feel better.

The pain was aggravated since one week and the patient was unable to walk, bear weight , take care of himself and was admitted in our hospital, diagnosed with hyperurecemia and dimorphic anaemia.

In hands:
Pain initially starts in the wrists,swelling appears ( flexion occurs at metacarpal- phalanges joint )for 1 to 2 days and pain migrates to elbow (unable to flex completely, swelling +) for 2 days and then pain migrates to shoulder (unable to lift ,abduct the shoulder )and then other hand involves.

Pain is asymmetrical (when one hand is involved the other is not involved)

In Legs:
Pain initially get started in the ankle (swelling+, duration 1-2 days and pain migrate to Knee (unable to bear weight, walk with help of stick/support, swelling+duration 1-2 days )and then pain migrate to hip joint.

Pain is asymmetrical (when one leg is involved the other is not involved.)
No C/O diarrhoea and vomitings

No C/O shortness of breath,palpitations,ornthopnea
Past illness :
Not a known case of DM,HTN,CVA,CAD,TB,ASTHAMA, EPILEPSY
 KNOWN CASE OF  IRON DEFICIENCY ANEMIA WITH POLYARTHRITIS (SERO NEGATIVE 

No similar complaints in past 

Family history:

No similar complaints in family 

Personal history:

1) Alcohol:Used to consume Toddy twice a week 6 to 7 years back. Now completely start consuming alcohol.

Appetite decreased

Bowl and bladder movement normal

Food:Mixed since 3-4 years back stopped consuming chicken and meat.

General examination:

No icterus,cyanosis,clubbing,lymphadenopathy.

PALLOR +

vitals

Temp - afebrile 

BP-100/60 mm hg 

PR-82 bpm

RR-19 cpm

Spo2- 100@RA

GRBS- 158 mg/dl @ 8am 

CVS-S1 ,S2 heard

RS-bae present 

P/A - soft, tender, guarding present

CNS-NAD

Examination of joints:

Wrist joint : partial movement of flexion and extension approximately 30-45 degrees 

Swelling+ at wrist joint

Fingers : unable to completely flex phalanges, stiffness+

Knee and ankle joint : unable to flex completely, but can flex up to 30 degrees

Swelling +,stiffness +

Elbow:Can flex and extend normally

Shoulder :can lift shoulders above the head but not 180° at shoulder joint

During pain unable to lift bucket

FAMILY HISTORY
Not significant

PERSONAL HISTORY
Diet - mixed
Appetite - Decreased 
Bowel and bladder - adequate
Allergies -no
Addiction -  no

GENERAL EXAMINATION
Thin built and malnourished 

Vitals
Temperature : Afebrile 
Pulse: 91
BP:100/60 mm/ hg
RR :26
SPO2 : 100%
GRBS:84 MG%

 Pallor : present 
Icterus : ABSENT 
Clubbing :ABSENT
Cyanosis :absent
Lymphadenopathy: absent

SYSTEMIC EXAMINATION
CVS
Apex beat 6 th intercoastal space
No thrills
S1 S2 heard
No murmurs



RESPIRATORY SYSTEM







INVESTIGATION

PROVISIONAL DIAGNOSIS
ANEMIA SECONDARY TO IRON DEFICIENCY SERO NEGATIVE . RHEUMATOID ARTHRITIS ? WITH CHRONIC KIDNEY DISEASE ? WITH CHOLILITHIASIS.

Rx

1) TAB OROFER XT PO/BD
       1--------------------1
2) TAB LIMECE PO/BD
        1--------------------1
3) TAB.REVIEW AFTER REPORTS
4) VITALS MONITORING 4TH HOURLY STRICT I/o monitoring
5) inform sis
6) INTRACET 1/2 TAB PO/ QIP
  1/2------1/2----1/2-----1/2

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