Bilateral knee pain since 5days Bilateral pedal edema since 5 days
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.
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.
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.
Orthopaedic referral was taken in view of left knee swelling and pain.
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
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
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
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
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
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???
Differential diagnosis???
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