Spondyloarthropathy with osteoarthritis of bilateral knees with bilateral SNHL

CBBLE UDHC SIMILAR CASES

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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 

55 year male,farmer by occupation 8 years back  came with chief complaints of pain in bilateral knees since 1 yr. And pain in back region,right wrist,eyes,neck since 1 yr.

Patient was apparently asymptomatic 1yr back and then developed pain in his back initially on the right and then 2 days later left region as well. This pain was insidious in onset,Non radiating and of dragging type. Morning stiffness present.

C/o pain in bilateral knees since 1 yr,insidious in onset,non radiating, stiffness in the morning, pain relieved o  walking. 

Bowing of legs present.edema upto above ankle present.

He is able to perform his daily activities. He is walking using the help of a walking stick.

H/o right wrist fracture 5-6yrs back.

C/o pain and swelling  of wrist on weight bearing.

C/o swelling next to umbilicus since 6 months.,reduced on lying downa.caugh impulse present.

Past history:

Not a K/C/O DM,HTN,TB,EPILEPSY, ASTHMA. 

PAST HISTORY:

Not a K/C/O DM,HTN, EPILEPSY, TB.

PERSONAL HISTORY:

DIET - MIXED,

APPETITE -NORMAL

BOWEL MOVEMENT - REGULAR , 

BLADDER MOVEMENTS - REGULAR, ADDICTIONS(ALCOHOL AND SMOKING) - NO ADDICTIONS

TREATMENT HISTORY:

NON SIGNIFICANT 

O/E:

PATIENT IS CONCIOUS , COHERENT COOPERATIVE

 NO ICTRUS 

 NO PALLOR 

No CLUBBING , CYANOSIS , LYMPHADENOPATHY, 

EDEMA-PRESENT.

VITALS - 

TEMPERATURE - 97' F

PULSE RATE - 72BPM

BLOOD PRESSURE - 130/70 MM OF HG 

RESPIRATORY RATE - 17

SPO2 - 99 % AT ROOM AIR

SYSTEMIC EXAMINATION - 

CARDIOVASCULAR SYSTEM : S1 AND S2 HEARD , NO MURMURS

RESPIRATORY SYSTEM : BILATERAL AIR ENTRY PRESENT ,NORMAL VESICULAR BREATH SOUNDS

CENTRAL NERVOUS SYSTEM : NAD

P/A - diffuse tenderness present, no organomegaly

?UMBILICAL HERNIA.

INVESTIGATIONS:

HB-12.7

TLC-7700

N/L/M/E-66/22/10/2

PLT-2.6

PCV-37%

RBC-4.35

SERUM CREATININE-1.3

Na-143,k-4.8,Cl-99

LFT:TB-0.9,DB-0.3,AST-17,ALT-9,ALP-188,TOTAL PROTEIN-6.6,ALB-4A/G: 1.66

RBS-104

SEROLOGY-NEGATIVE.

ECG-

Chest X ray:

Ortho referral :

1.Tricompartmental OA changes in both knees

2.Malunited distal radius fracture of right hand

3.Lumbar spondylitic changes with osteoporosis in LS spine

DIAGNOSIS: Spondyloarthropathy with osteoarthritis of bilateral knees and bilateral sensory neural hearing loss

TREATMENT:

1.TAB.ULTRACET PO OD 

2.TAB.SHELCAL PO OD 

3.TAB.PAN 40 MG PO OD.