20100006010 CASE PRESENTATION
LONG CASE
48 year old male patient from devarakonda,Farmer in cotton field and also works as daily wage labourer ,came with the cheif complaints of
Burning sensation of both lower limbs since
8months
Slippage of slippers since 8months
Hypo pigmented skin lesions on both lower limbs since 8months
HOPI:
Patient was apparently asymptomatic 8months ago when he developed difficulty in holding slippers ,gradually progressive and worsened over last 2months so much so that he stopped wearing slippers,No difficulty in getting up from squatting position,mixing food ,buttoning the shirt,combing hair,no difficult in lifting the head off the pillows,rolling over the bed,no difficulty in breathing or diurnal variation of the weakness
Complaints of burning sensation of both lower limbs gradually progressive since 8 months and has worsened over the last 2months associated with numbness,decreased sleep because of burning sensation,Not associated with tingling or paraesthesias.Patient is able to feel clothes and warm water and cold water during bath.
Complaints of severe pins and needle sensations over outer aspect of leg and patient noticed that when he taps his leg just below the knee on the outer aspect he feels a shock like sensation and pain radiating down on the outer aspect of both legs.No h/o any excess crossed leg sitting posture
No h/o any sensation of walking on cotton wool,no complaints of neck pain ,back pain,band like sensation,
Unsteadiness on closing the eyes+
No h/o Washbasin attacks
No h/o any loss of consciousnesses or altered sensorium,seizures,head injury or trauma to the leg,speech disturbances,no bowel or bladder incontinence,memory disturbances
Sleep disturbances+
No h/o any delusions,hallucinations,emotional disturbances
No h/o any altered no difficulty in sensing smell,vision ,hearing
No tinnitus ,vertigo taste
No difficulty in lifting shoulder,deviation of mouth
Able to roll the tongue and push the food backwards
No h/o any spillage of food while taking it to the mouth or clumsiness of hands
Unsteadiness while walking and closing eyes+
No h/o any palpitations,sweating,able to feel bladders fullness,initiate micturition,feel the passage of urine,able to completely evacuate the bladder
No h/o any bowel disturbances
No h/o Fever ,vomitings,neck pain,trauma,lifting heavy objects on head /back,headache,vomiting,diarrhoea,
Incidentally found to be hepatitis B positive 20days back
Complaints of hypo pigmented skin lesions over both lower limbs since 6months and reduced sensations over the skin lesions.
Complaints of weight loss of 7kgs over the last 4-5 months.
Complaints of transient pain in right upper abdomen and was treated conservatively for gall bladder stones 10days ago.
Past history:
Not a k/c/o DM,HTN,CKD,epilepsy,asthma,TB
No h/o similar complaints in the past
Personal history:
48 Yr old male studied upto 10th class and stopped further studies because of financial issues and started working as a farmer.
Married at the age of 15
Has 1Son 2daughter,all of them married
Alcoholic since 25years and stopped one year back
Non smoker
Mixed diet
Regular bowel and bladder habits
Disturbed sleep patter since 2months
Family history:
No significant family history.
Treatment history :
tenofovir alfenamide since 20days
Pregabalin
Summary:Chronic,Progressive,Distal muscle weakness and sensory involvement probably due to lesion at the level of peripheral nerves at multiple levels ,likely secondary to a infective etiology (Hansens)
General examination:
Patient is conscious,coherent ,cooperative
Thin built
Afebrile to touch
pallor absent
No icterus ,cyanosis,clubbing,lymphadenopathy,pedal edema,no evidence of any neurocutaneous markers
Vitals:
PR:86bpm ,Regular ,normal volume,character,No RR delay,RF delay
BP: 110/80mmhg measured in upper limb in sitting position
Postural drop :absent
RR: 16/min regular ,abdominothoracic
Temp: afebrile
CNS:
Higher mental functions:intact
Cranial nerve examination:
Olfactory-Normal
Optic-
Visual acuity. Cf6 both eyes
Pupils:B/L Normal size,Direct and indirect reflexes +
Accomodation reflex+
Occulomotor,trochlear,abducens
No ptosis,EOM normal
Trigeminal:
Chewing normal
Facial sensations normal
Facial:
Frowning normal
No deviation of mouth
Vestibulochoclear:
Rinnes-AC>BC both ears
Webers-no lateralisation
Glossopharyngeal
Uvula central
Vagoaccesory
Shrugging of shoulders normal
Hypoglossal
Normal tongue movements
MOTOR
Attitude :Sitting on the couch with hands placed on the sides and bilateral foot dangling downwards
Bulk: R. L
UL-Arm. 22cms. 22cms
-Forearm. 21cms. 21cms
LL. -Arm. 33.5cms. 33cms
-Forearm. 24.5cms. 24.5cms
Tone.
Ankle: Hypotonia Hypotonia
Upper limbs and knee normal. Normal
Power:
1.neck flexion. Normal
2.Neck extension Normal
R. L
Upper limb. All: 5/5. 5/5
3.Supraspinatus.
4.Deltoid
5.infraspinatous
6.Rhomboids
7.Serratus anterior
8.Pectoralis major
9.Lattismus dorsi
10.Biceps
11.Brachioradialis
12.Triceps
13.Hand muscles
Trunk muscles :Normal.
Lower limbs:
1.Iliopsoas. 5/5. 5/5
2.adductor femoris 5/5. 5/5
3.Gluteus medius. 5/5. 5/5
4.Gluteus maximus 5/5. 5/5
5.Hamstrings. 5/5. 5/5
6.Quadriceps femoris. 5/5. 5/5
7.Tibialis anterior. 0/5. 0/5
8.Tibialis posterior. 5/5. 5/5
9.peronei 0/5. 0/5
10.FDL. 5/5. 5/5
11.EDL. 0/5. 0/5
12.EHL. 0/5. 0/5.
13.EDB. 0/5. 0/5
Reflexes:
Superficial reflexes:
Corneal+
Conjunctival+
Abdominal
Plantar. Mute. Mute
DTRs:
Biceps. 2+. 2+
Triceps. 2+. 2+
Supinator. 2+. 1+
Knee. 2+. 2+
Ankle. Absent. Absent
EXAMINATION VIDEO:
Gait:High stepping/equine gait
No primitive reflexes
No involuntary movements
SENSORY:
Crude touch
Upper limbs -normal bilaterally
Trunk-normal
Lower limbs-reduced in the lower 1/3rd of anterolateral leg
Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally
Pain:
Upper limbs -normal bilaterally
Trunk-normal
Lower limbs-reduced in the lower 2/3 rd of anterolateral leg
Reduced over the Dorsum of foot,web space between 1,2nd toes,lateral aspect of foot bilaterally
Vibration:Reduced distally
Timed Vibration test: R. L
Lower limbs:
Great toe. Absent. Absent
Medial mallelus. Absent. Absent
Knee. Absent. 4.5Sec
Upper limbs:
Ulna. 6.7sec. 7.0sec
Medial epicondyle. 7sec. 7.2sec
Joint position. Absent. Absent
Fine touch :normal in all limbs ,trunk except for reduced fine touch in lower 3rd of anterolateral leg,dorsum of foot
Absent fine touch in the web of 1st and 2nd toe in right lower limb and reduced in left lower limb
Rombergs -Positive (swaying with eyes closed)
Stereognosis: normal
Graphaesthesia:Normal
Tactile localisation:couldn’t be elicited properly
CEREBELLAR SIGNS:
No titubation
Finger nose test,Finger finger test-normal
Heel knee test -normal
No rebound phenomenon
No dysdiadokokinesia
ANS:
Postural hypotension-absent
Resting tachycardia -No
Abnormal sweating -No
MENINGES:
No signs of meningeal irritation
SPINE AND CRANIUM:
normal
No spinal tenderness
PERIPHERAL NERVES:
-Thickened nerves:
Lower limbs :
Bilateral common peroneal palpable
Bilateral sural nerve palpable
Tibial nerve-not palpable on both sides
Upper limbs:
Ulnar nerve -Palpable in left cubital tunnel
-No ulcers
-bilateral foot drop +
-No wrist drop
CAROTIDS pulse-Normal ,no bruit
LOCAL EXAMINATION-
Multiple marked hypopigmented and hypoanesthetic patches seen over bilateral foot
Asymmetrical
Surface:Dry
surrounding erythema :absent
central healing:No
elevated margin:present
Clarity of margin:good
CVS:Apex 5th ICS,0.5 inch medial to mid clavicular line,Heart sound normal ,no murmur
RS:Tracheal central,Chest elliptical bilaterally symmetrical
Chest movements normal
Normal vesicular breath sounds
P/A :Soft,Non tender
No organomegaly .
Final diagnosis:Chronic peripheral neuropathy with Mononeuritis multiplex pattern involving bilateral superficial peroneal,deep peroneal,Sural nerves in both sensory and motor component with both small and Large fibre involvement
DD1:Most probably secondary to Hansens(Late stage as large fibres are also involved)
In favour of :?Borderline Tuberculoid leprosy,
Few skin lesions with
Early nerve involvement
Assymetrical nerve thickening
Hypesthesia and myopathy
DD2:L5 radiculopathy
Justification for Not radiculopathy:
1.No radicular pain
2.No spinal tenderness
3.No clear cut dermatomal distribution of sensory loss
DD3:Hepatitis B induced peripheral neuropathy? Polyarteritis nodosa with mononeuritis multiplex
DD4:Vasculitis -PAN,Wegeners
1.Age not in favour
2.Hypopigmented hypoanesthetic patches can’t be justified
3.No h/o any constitutional symptoms,Organ dysfunction
4.small fibre involvement predominates
DD5:
Diabetes
Not in favour because:
1.In diabetes Small fibre predominates
2.No history of diabetes
DD6:
Lymes disease:No evidence of any erythema chronicum,Fever,Arthritis
DD7:
Entrapment:Sarcoidosis,Amyloidosis
No other evidence suggestive of these
Further evaluation needed:
1.Slit skin smear from the most hypoanaesthetic macule and skin biopsy
2.Nerve biopsy
3.Nerve conduction study
4.Serology -HIV ,Hepatits B,C
5.HBV viral load,Fibroscan,LFT
6.FBS,PLBS for any impaired glucose tolerance and diabetes
INVESTIGATIONS:
Hb:9.9gm/dl
TLC:7,800
Platelets :2.91
PBS:NC/NC
RBS 80
Urea:32
Creatinine:0.7
Na:141
K:4.1
Cl:102
Total bilirubin 0.37
Direct bilirubin 0.19
AST 16
ALT. 19
ALP. 162
Total protein 5.3
Albumin 3.1
A/G:1.45
CUE:WNL
HBsAG +
HCV-
HIV -
USG abdomen:Norma size and echotexture of liver,cholelithiasis +
ECG:
Nerve conduction study done 8 months ago:Showing reduced CMAP s in bilateral common Peroneal nerve and reduced SNAP in left sural nerve
-----------------------------------------------------------------------------------------------------------------
SHORT CASE I
CHIEF COMPLAINTS
Abdominal distension since 3 months
Shortness of breath since 3months
Pedal edema since 3 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 4 months ago, then he developed yellowish discolouration of eyes ,intermittent and reappeared again since 4days not associated with itching,discolouration of urine or stool
Abdominal distension which was insidious in onset , gradually progressive in nature since 3months,not associated with pain abdomen.
He complained of shortness of breath since 3months (grade 2) upon doing ordinary activity like walking to his field after eating.He used to walk 2km without any inconvenience but since 3 days he is able to walk upto 1km only. He also complained of pedal edema since 3days which was insidious in onset, gradually progressive and confined upto ankles( grade 1) and pitting type.
H/O decrease in urine output since 3 days and difficulty in passing stools and passing hard stools since 3 days which relieved on taking medication.
H/ O yellowish discolouration of eyes on and off since 4months
No H/O blood in urine, burning micturition, increased frequency and urgency.
No H/O orthopnea, paroxysmal nocturnal dyspnoea
No H/O abdominal pain, nausea ,vomiting, dark stools and diarrhoea.
No H/O chest pain, palpitations, facial puffiness
No H/O fever, chills, rigor, myalgia, joint pain and rashes.
No H/o any blood transfusions
No H/o any bleeding manifestations
3 months back diagnosed as decompensated liver disease for which he was treated here and he continued taking medication since discharge and stopped taking them since two days before developing the recent symptoms.
Endoscopy was done here 3 months back and oesophageal varices were detected.
PAST HISTORY:
No H/O hypertension, diabetes mellitus, tuberculosis, asthma, coronary artery disease, epilepsy.
No H/O any surgeries.
FAMILY HISTORY
No similar complaints in the family.
PERSONAL HISTORY
Patient is a 50 year old male hailing from thanamcherla, who is farmer by occupation, married( consanguineous) at 20 years and has three children.(2daughters and 1 son)
Stays along with his wife and son.
Daily routine : He wakes up at 5'O clock and goes to his 1acre farm by walk, comes back after an hour, eats breakfast and lunch which are rice and vegetable.He takes afternoon nap for one hour, then again goes to his farm for sometime and comes back for dinner and then sleeps.
Sometimes he also goes for work at municipal office and from there to cleaning roads,schools.
Diet : vegetarian, stopped eating non vegetarian foods 3 months back.
Appetite : normal
Sleep : adequate
Bowel movements: decreased
Bladder movements: decreased
Addictions : Alcoholic since 30 years but Started drinking more alcohol along with his friends at municipal office,he had been drinking 1litre of sara (Local alcohol) from the last 10-15years, but stopped from past 3 months on doctor's advice.Slowly drinking with his municipal office friends has become his daily routine.
GENERAL EXAMINATION:
Patient is conscious,coherent and co operative, well oriented to time, place and person
Patient is moderately nourished and moderately built
Height -5’5
Weight -60kgs
Pallor -present
Icterus -present
Cyanosis- absent
Clubbing - absent
Lymphadenopathy - absent
Pedal edema - present (grade 1,pitting type)
Parotidomegaly+
EXTERNAL MARKERS OF LIVER CELL FAILURE
HEAD AND NECK- No alopecia, no bitots spots, no xanthelasma, subconjunctival hemorrhage, pallor +, icterus+, no medial supraciliary madarosis, sunken eyes and cheeks, loss of facial hair, no parotid enlargement, bleeding gums
TRUNK - no spider nevi, no gynaecomastia, loss of pectoral/axillary hair present, no dilated veins, wasting, abdominal distension present, no caput medusae, no loss of pubic hair, no testicular atrophy, no scratch marks, purpura
UPPER LIMBS - dupuytrens contracture present, no bounding pulse, no clubbing, no flapping tremor, no palmar erythema, no pruritic marks
LOWER LIMBS - Pedal Edema present
NO BONY TENDERNESS, GUM HYPERTROPHY, LEUKEMIA CUTIS
VITALS
Afebrile
Blood pressure-110/70mm Hg
Pulse-78bpm,Regular rhythm,normal volume and character and no RR ,RF delay,all peripheral pulses normal
RR-18cpm, abdominothoracic
SYSTEMIC EXAMINATION
ABDOMINAL EXAMINATION:
INSPECTION-
Abdomen is distended
Umbilicus is inverted
Skin is normal without any scars
No discolouration of skin ,engorged veins,sinuses
No visible peristalsis or pulsations
Hernial orifices Normal
Movements of abdominal wall equal in all quadrants with respiration
External genitalia normal
PALPATION-
Superficial palpation:Abdomen is non tender and no local rise in temperature
No guarding and rigidity
Deep palpation:Palpation by dipping method -No organomegaly
PERCUSSION-
liver :Upper border of liver dullness is percussed at the right 6th ics along mid clavicular line and lower border cannot be palpated
Spleen:cannot be palpated
No fluid thrill
shifting dullness present
AUSCULTATION-
Bowel sounds heard 12/min
No bruit or venous hum
PER RECTAL:stool stained
CNS EXAMINATION:
No flapping tremors
Conscious,coherent and cooperative
Speech- normal
No signs of meningeal irritation.
Cranial nerves- intact
Sensory system- normal
Motor system:
Tone- normal
Power- bilaterally 5/5 in all limbs
Reflexes: Right. Left.
Biceps. ++. ++
Triceps. ++. ++
Supinator ++. ++
Knee. ++. ++
Ankle ++. ++
CARDIOVASCULAR SYSTEM EXAMINATION:
Inspection :
Shape of chest- elliptical ,bilaterally symmetrical
No engorged veins, scars, visible pulsations
JVP - not raised
Palpation :
Apex beat can be palpable in 5th inter costal space half inch medial to MCL
No thrills and parasternal heaves can be felt
Auscultation :
S1,S2 are heard
no murmurs.
RESPIRATORY SYSTEM EXAMINATION:
Inspection:
Shape- elliptical
B/L symmetrical ,
Both sides moving equally with respiration .
No scars, sinuses, engorged veins, pulsations
Palpation:
Trachea - central
Expansion of chest is symmetrical.
Vocal fremitus - normal
Percussion: resonant bilaterally
Auscultation:
bilateral air entry present. Normal vesicular breath sounds heard.
PROVISIONAL DIAGNOSIS
Decompensated chronic liver disease (Cirrhosis)2° to chronic alcohol consumption with ascites with history of esophageal varices without any upper GI bleed with no evidence of hepatic encephalopathy,Spontaneous bacterial peritonitis or other complications
INVESTIGATIONS
USG ABDOMEN:
Irregular coarse echotexture of liver
Mild splenomegaly
Gross ascites s/o chronic liver disease
ECG
CHEST X RAY
ECHO
No RWMA,Good LV systolic function,No PAH
HEMOGRAM :
Hb-9.5g/dl
TLC-8,800cells/cumm
Platelets-1.71lakhs/cumm
PBS-normocytic normochromic anemia
LFT
Total bilirubin-1.65mg/dl
Direct bilirubin-0.25mg/dl
AST-20IU/L
ALT-11IU/L
ALP-205IU/L
Total protein 5.9gm/dl
Albumin -2.0
A/G-0.54
RFT-
Urea-14
Serum creatinine-0.9
Na+ 136
K+ 3.4
Cl- 102
PT-19sec(PTc-10-16sec)
INR-1.4
APTT-39sec(APTTc-24-33sec)
Rapid HCV Negative
Rapid HBV Negative
Ascitic fluid analysis
Cell count -100cells/cumm,100% lymphocytes
Glucose-165
Protein-1.0
Serum albumin-2.0
Ascitic Albumin-1.0
SAAG-2
Gram stain-No growth
Culture and AFB negative
Endoscopy:Grade 4 esophageal varices
Final diagnosis-Chronic Decompensated liver disease secondary to alcohol with features of portal hypertension such as ascites,esophageal varices,Splenomegaly with no evidence of hepatic encephalopathy,SBP
Treatment:
1.Fluid restriction
2.Salt restriction
3.Therapeutic paracentesis done-1litre
4.Tab LASIX 40mg BD
5.Tab aldactone 50mg BD
6.Syrup Lactulose 20ml PO TID
Child Pugh score -9, Grade B with one year survival at 80% and 2 year survival at 60%.
Counselled about liver transplantation
----------------------------------------------------------------------------------------------------------------
SHORT CASE II
45 year old female currently working as ECG technician and previously worked also a tailor ,hailing from Nalgonda with the chief complaints of multiple joint pains and swellings since 17years
HOPI:
Patient was apparently asymptomatic 17years ago and then developed multiple joint pains,Started with left ankle severe pain and swelling,Gradually progressive ,involving multiple joints ,bilaterally symmetrical,involving ankle joints,knee,hips,shoulder ,elbows to currently involving wrist ,ankle pain still present .History of neck pain 5-6years ago subsided now,3days back history of pain during chewing on lateral cheek with swelling on both sides, relieved after 1day.Pains Relived transiently with pain killers.
Pain Relieving on activity Morning stiffness lasting 20-30ki minutes.No h/o any Deformities.
No h/o any fever,Oral ulcers,facial rash,photosensitivity,breathing difficulty,tingling numbness of limbs or weakness of limbs,bleeding manifestations
PAST HISTORY:
Hypothyroidism diagnosed 10YEARS ago (visited hospital in view of weight gain)
Epigastric pain—>Gastric ulcer detected 2years ago
Diabetes incidentally detected 1year ago
Diagnosed to be having Seronegative Rheumatoid arthritis 15years ago (Anti CCP,ANA negative,CRP+)
H/o ?Insecticide poisoning 20years ago managed conservatively.
No H/o Asthma,COPD,TB,DM,HTN,CAD,Epilepsy
PERSONAL HISTORY:
Mixed diet
Appetite good
Bowel and bladder habits regular
Sleep adequate
No addictions
H/o weight gain 60->75kgs over 15years
Sleep adequate
No Food allergy
FAMILY HISTORY:
No significant family history
MENSTRUAL HISTORY:
Age of menarche-13years,5/28,no clots,normal flow
OBSTETRIC HISTORY:
P2L2A0
2children ,by LSCS
Last child birth:20years ago
1st child -Male
2nd -female
TREATMENT HISTORY:
Tab WYSOLONE 5mg OD used for 3years,5years ago
Tab Methotrexate 15mg once weekly used 5 years ago
Tab HCQ started 4 years Ago and used for 3 years
Tab Sulphasalazine 1000mg started 4years
Tab Metformin 500mg PO OD
Tab Pantoprazole 40mg OD
Provisional diagnosis:Bilaterally symmetrical chronic progressive inflammatory peripheral polyarthritis
EXAMINATION:
Patient is conscious,coherent and cooperative
Well built,well nourished
Height :155cms
Weight:74kgs
BMI:
VITALS:
Pulse:96bpm ,regular,normal volume and character,condition of vessel wall,no RR or RF delay
BP:140/80mmhg in right arm in supine position
Temp:Afebrile
RR:24cpm
GENERAL PHYSICAL EXAMINATION:
Pallor present
Icterus absent
Cyanosis absent
Clubbing absent
Lymphadenopathy absent
Edema-Bilateral pitting type of pedal edema upto lower 3rd of legs
Other head to toe findings:
No scarring or non scarring alopecia
Eyes normal
Skin ,Nails normal
Oral cavity normal
Pictures showing ankle swelling
LOCOMOTOR SYSTEM EXAMINATION:
1.PIP :Normal
2.DIP:Normal
3.MCP:Normal
4.Carpo metacarpal:Mild Tenderness + over 1st 2 carpometacarpal joints on both sides
5.Wrist :normal on inspection ,palpation and normal range of movements
6.Elbow:placed in mid flexion,normal alignment of arm and forearm,no muscle wasting,no tenderness,3point bony relation intact,ROM normal
7.Shoulder:
Slightly flexed internally rotated,normal contour,no edema or erythema,no increase in local temperature,Range of movements normal,Overhead abduction slightly painful
8.Acromioclavicular: Normal
9.Sternoclavicular:Normal
10.Temporo Mandibular joint:
Tenderness+,chewing movements normal,mild swelling +
11.Hip joint
Normal on inspection,palpation and normal range of flexion and extension
12.Knee joint
Inspection:swelling present ,in flexion attitude
ROM:
13.Ankle joint
Tenderness on plantar and dorsi flexion+
Painful restriction of motion(flexion ,extension,inversion and eversion)
Achilles tendon palpation normal
14.Subtalar joint
Tenderness +,Swelling+
15.small joints of foot
MTP:Normal
Great toe:Normal
Examination of Spine:
Cervical spine:
Atlanto axial joint -normal neck flexion and extension
Atlanto occipital joint -normal neck rotation
Thoracolumbar spine : normal on inspection ,palpation
Sacroiliac joint:No tenderness,Schobers test negative
Examination of Respiratory system,Cardiovascular system,CNS,Per abdomen -Normal
PROVISIONAL DIAGNOSIS:
Bilaterally symmetrical chronic progressive peripheral polyarthritis
DD:
1.Rheumatoid arthritis
2.Sero negative arthritis-?Reactive,?Psoriatic
3.Connective tissue diseases,SLE
ACR/EULAR criteria:
Number of joints involved-Multiple small and large joints:5points
Symptoms >6weeks:1 point
RA factor negative:0 points
CRP ESR elevated :1point
Total 7/10
INVESTIGATIONS:
CBP
Hb-9.8
TLC-8600
N/L/E/M/B-68/25/2/5/0
Platlets -4.5
MICROCYTIC HYPOCHROMIC ANAEMIA
FBS-106
PLBS-241
HbA1c-7.0
THYROID PROFILE
T3-1.06
T4-12.03
TSH-4.15
LIPID PROFILE
Total cholesterol-190
Triglycerides-238
HDL-39
LDL-118
VLDL-47.6
RFT
Urea-24
Creatinine -0.7
Uric acid-2.2
Calcium-9.3
Phosphorus -3.1
Sodium-135
Potassium-4.6
Chloride-101
LFT
Total bilirubin-0.60
Direct bilirubin -0-15
SGOT-22
SGPT-17
ALP-173
Total proteins-5.8
Albumin -3.5
A/G ratio-1.58
RA factor:Negative
Anti CCP :Positive
X ray hands:osteopenia and erosions of MCP and PIP joints,Ankle
Decreased joint space in bilateral knee joint
Final diagnosis:Bilateral symmetrical erosive polyarthritis -Rheumatoid arthritis since 15years with hypothyroidism since 7 years and diabetes mellitus since 1 year
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