respected all & hi please dignosis & treatment but repeatedly again & again both lower limb 1 month plese help

f 60 years c/o polyarticular joint pain with morning stiffness 5 years gastric burn puffiness on face first treated by medical college of nepal with diagnosis of RA w/ raised uric acid level after that pt goes to a quack and he gave her aceclofenac thiocholchicoside with methyprednisolone now again she comes with pain and joint stiffness bp 156/80 pulse 86 bpm anasarca present ROM restricted plz guide me about further treatment

RHEUMATOID ARTHRITIS RA is a type of inflammatory arthritis. Other examples include seronegative spondyarthritides, reactive arthritis, lyme arthritis, crystal arthritis and postviral arthritis. Features of inflammatory arthritis : ●Pain and stiffness worse in the morning and after rest. ●Early morning pain and stiffness may last several hours (in OA, duration is much shorter). ●Inflammatory markers (ESR, CRP)usually raised. ●Often accompanied by normochromic, normocytic anaemia. This is a chronic symmetrical arthritis. When we say it is symmetrical, we don’t necessarily mean a mirror image, just that the same joints are affected on both sides of the body. it is also important to remember that RA is a systemic condition, with many extra-articular manifestations. This is a chronic symmetrical arthritis. When we say it is symmetrical, we don’t necessarily mean a mirror image, just that the same joints are affected on both sides of the body. it is also important to remember that RA is a systemic condition, with many extra-articular manifestations. Typically it affects the peripheral joints, and there is inflammation of the joint (synovitis). Deformity is common and the course is extremely variable. Epidemiology and Aetiology : ●Affects 0.5-3% of the population worldwide. ●Can present at any age (from childhood to old age), but the peak incidence is between 30-50 years. ●women affected more than men (M:F – 1:2). ■before the menopause, risk is 3x higher for women . ■after the menopause it is equal. ■suggests sex hormones involved in some way. ■the contraceptive pill can delay the onset, but does not reduce the risk. ●Genetic factors are involved. Certain HLA variants are implicated, especially in severe forms of the disease:. ●HLA-DR4 – occurs in 50-75% of patients, and is associated with a particularly poor prognosis. ●HLA-DR1 is another variant associated with RA, and poor prognosis. ●Environmental factors: ¤Smoking ¤Stress ¤Infection Clinical features : Most commonly, the condition will present as progressive over weeks to months. These patients have the worse prognosis. But in some cases it can come on in days, or even overnight. Also, it is almost always a polyarthritis, but some cases do present as monoarthritis, most commonly of the knee or shoulder, or with carpal tunnel syndrome. ●symmetrical swollen distal joints. ●Often warm and tender joints. ●sometimes presents as a sudden onset of widespread arthritis, but this is rare. ●Typically the joint of the hand (MCP, DIP and PIP’s)and the distal metatarsals of the foot. ●Sometimes it affects the wrists, elbows, shoulders, knees and ankles. ●Hips are very rarely affected. ●Limitation of movement. ●Muscle wasting. ●Pain and stiffness – worse in the morning, may improve with activity. It is often described as an ache type pain. ●Disturbed sleep. ●Nodules – in the early and mild stages of the disease, there are relatively few inflammatory cells in the joints. As the disease progresses, these increase in number and there may be nodular masses of inflammatory cells within the joint. Rheumatoid nodules occur when these inflammatory cells form similar inflammatory structures outside of the joint capsules. The nodules are usually pink/red and have a rubbery texture. They are painless. You should always check the elbows in a hand exam, looking for rheumatoid nodules!. ●Osteoporosis – often occurs in the bones immediately around the affected joints, particularly in the fingers. This may be the first sign of RA. ●Secondary Osteoarthritis. ●Deformity – as the joint capsule is destroyed, and the articular surface damaged, deformity occurs. Specific examples include ●Hands ¤Swan necking – the fingers become hyperextended at the PIP, and flexed at the DIP. ¤Z-thumb. ¤Subluxation of the MCP –not that this is not swelling!. ¤Muscle wasting – “guttering” – ‘gutters’ seen between the extensor tendons on the back of the hand. ●Why do the muscles waste so quickly in joint disease? –  In a normal individual, if you don’t use a muscle, it will waste at a rate of about 1% of its mass/day. However, in joint disease, the rate of wasting in much greater. This is because in joint disease, there is inhibition of nerve afferents, for nerves that innervate the muscles around a joint. This alters the muscle tone/reflex feedback loop, leading to decreased innervation of the muscle, and as a result, wasting occurs very quickly. ●Inflamed flexor tendon sheaths – these serious impair function. ●Carpal tunnel syndrome is common. ●Ulnar deviation – the fingers point towards the ulnar side. ●Fixed flexion deformity – aka buttonhole or boutonniere deformity. ●Shoulders – Shoulders are commonly affected, and at first it may mimic rotator cuff tendonitis. Later, the joint becomes stiffened. Rotator cuff tears can occur late on. ●Elbows – less commonly affected. Flexion may be lost, which makes eating very difficult. ●Knees – massive synovitis and effusion. These respond well to steroid injection and aspiration. A persistent effusion may increase the risk of cyst formation, and these can rupture. Varus or valgus deformity can occur, and there may be joint space narrowing and secondary OA.Knee replacement can restore much of the function, and relieve pain. ●Cervical spine – pain in the neck is more commonly muscular, but you can get joint disease itself in the cervical spine. There can be bone destruction, which poses a risk to the spinal cord.Be wary loss of sphincter control, or unexplained weakness in late RA – could be due to cord compression!. ●Feet – often the first signs of the disease may only be in the feet. The patient may describe an uncomfortable sensation that feels like walking on marbles. This is due to subluxation of the heads of the metatarsals in the feet. Presentations : ■Palindromic – monoarticular attacks, last 24-48 hours. 50% of cases will progress to other types of RA. ■Transient – lasts <12 months, then permanently remits. Usually seronegative. No lasting damage. ■Remitting – may be active for several years at a time, before remitting. Lasting damage is minimal. ■Chronic, persistent – the most common form. May be seronegative or seropositive. Follows a relapsing remitting course over many years. Seropositive patients have worse joint disease and higher risk of long-term disability. ■Rapidly progressive – rapid progression occurs over several years. Severe joint damage, disability and high rate of complications. Normal initial investigations : ■Blood count: ●Anaemia. ●ESR/CRP raised due to inflammation. Monitoring levels of these can be used to assess treatment . ■Serology – check for rheumatoid factor – only present in 70% of cases. ¤ANA’s – anti-nuclear antibodies – these are also regularly tested for, and show up in 30% of cases. ¤Anti-CCP – testing for this is becoming more common. ■X-ray – useful to get a baseline reading at the start of the disease. Normally only soft tissue swellings initially. Later there may be:¤Boney erosions. ¤Osteopenia (lower than normal bone density). ■Joint aspiration – in the presence of effusion. Aspirate will appear cloudy due to the presence of white cells. If the joint is suddenly painful, always aspirate to check for septic arthritis, as this can rapidly destroy joints. ■MRI – very rarely used, but can show early bone erosions. Also used in widespread disease to assess the extent of the joint damage.

19 yr old female pt. comes with evening time severe nausea for 20 day then it get relieved itself after 20 days..pt also gives history of cough and fever for 7 days ..pt also gives history of pain abdomen at different locations mild in intensity..pt also gives history of weight loss...no history of blood in stools or malena ...on examination pallor is present ..abdomen examination is normal.. on USG inflammed terminal ileum is seen ..report is enclosed within

F.70. Pain right knee and unable to flex. H/O Surgery Rt. knee 12 years back.