30 yrs female with MULTIPLE JOINT PAINS AND SWELLING

presentation videohttps://youtu.be/iXyGc1ZnU5Q

Chief complaints::::

A 28yr old female resident of ramannagudem came to the OPD with C/0 MULTIPLE JOINT PAINS  since 2 months                                   a/w loss of appetite, and low grade fever Since 2months.

HISTORY OF PRESENT ILLNESS::

Patient was apparently asymptomatic 2 months back Then On missing her periods she got her UPT done which confirmed her pregnancy    Few days later she developed left foot pain initially in the early morning- burning type when pain progressed to the other side(right side).                                                                                Then joint pains were ascending and involved knee , hip joints within 1 months, with left knee joint swelling since 15-20 days.          Wrist pain since 20 days                        Difficulty in fisting the hand since 10-15 days.mild back pain sice 15 days
Fever since 1 month- evening rise of temperature on and off No cough , no loose stools, no vomitings. Not associated with chills and rigor. 
NoH/o TRAUMA,
 Daily Routine :: patient was homemaker by occupation   She wakes up at 8. 30 am does  her breakfast around 9 30 am. As she is suffering with pain she could barely perform her routine activities..She  takes her lunch around 1 30 pm and takes afternoon nap from 2 to 3 pm .. She will have dinner around 8 pm and  goes to sleep by 9 pm. Routine was not disturbed before 2months  but  later developed pain insidious onset pain in left ankle and foot which was severe on morning after wake up burning sensation on foot when walking and later she developed difficulty in doing her regular activities.so visited to hospital

PAST HISTORY::

H/O MTP 1yr back for unplanned pregnancy. 
N/K/O DM, HTN,CAD,ASTHMA,TB

Obstetric history::
G2A1
Lmp::1st September


Personal history:

Appetite-Decreased
Diet-mixed
Regular bowel and bladder movements
Sleep.adequate
No addictions

Family history:
Not significant

Obstetric history:
H/o MTP 1yr back for unplanned pregnancy
Present pregnancy:10weeks of gestation

On examination:

On prior consent 
Pt is conscious coherent cooperative
Built: moderate
Nourishment: moderately nourished
No pallor ,icterus, clubbing,cyanosis,generalised lymphadenopathy,pedal edema


Vitals:
Pt is afebrile
Bp:110/70mm of Hg
Pr:68bpm
Rr:16cpm
Spo2: 98% at room air

Local examination::

Joint examination::left knee joint

On inspection:
....Mild swelling over knee joint
...More diffuse over supra pattelar area
...No scars or sinus over swelling
...No deformity 
.. stiffness of joint.positive
On palpation::
..local rise of temperature
... Tenderness present 
... swelling was diffuse but more prominent over supra pattelar area,
...no crepitus
...patellar tap...negative

Cvs::

s1s2+
No murmurs

Respiratory system:

Shape of chest:B/L symmetrical
Trachea:central
No wheeze no dyspnoea
Vbs+ve

Per abdomen::

P/a:soft,non tender
Liver ,spleen not palpable
Bowel sounds+

CNS::
 
Consious
Speech was normal
No abnormalities detected

Investigations::

CBP::

HB..11.1gm/dl
Tc..7,700c/mm3
Neutrophil..64
Lymphocytes..28
Eosinophil..03
Monocyte..05
Basophil..00
Pcv .32.2vol%
MCv..85.4fl
Mch .29.4pg
Mchc..34.5%
RBC..3.77M/Cumm
Platelets count..2.12lak/cu.mm

NORMOCYTIC NORMOCHROMIC..SMEAR

SERUM CREATININE::
 0.7

SERUM ELECTROLYTES::

SODIUM..141MEQ/L
POTASSIUM..3.6MEq/L
CHLORIDE..96 Meq/L

ESR::. 125 mm/1st hour

LFT::

TOTAL BILIRUBIN..0.52
DIRECT BILIRUBIN..0.20
SGOT..23
SGPT..16
ALKALINE PHOSPHATASE..462
TOTAL PROTIENS .6.9
ALBUMIN..1.07
A/G ratio .0.18

CUE::

COLOUR.pale yellow
APPEARANCE..clear
REACTION..acidic
ALBUMIN..nil
SUGAR..nil
BILE SALTS..nil
BILE PIGMENTS..nil
PUS CELLS..2-3 EPITHELIAL CELLS..1-2
RBCS..nil
CRYSTALS..nil
CASTS .nil

Rheumatoid factor..   negative

USG knee::

Swelling over Lt.knee joint
E/o.MILD FREE FLUID NOTED IN LEFT KNEE JOINT WITH SYNOVIAL THICKENING
MUSCLES OF ANTERIOR COMPARTMENT OF THIGH ARE NORMAL

IMPRESSION..  LEFT KNEE JOINT EFFUSION WITH SYNOVIAL THICKENING

PROVISIONAL DIAGNOSIS:
Spondyloarthropathy
1st trimester pregnancy

Treatment :
1.Tab.DOLO 650MG PO/SOS
2.TAB.MVT PO/OD@ 4PM
3Tab.folic acid 5mg
4.Monitor vitals 
5.tab.HYDROXYCHLOROQUINE 100MG H/S

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