Mr KMZ, a 64- year-old retired business man, visited our rheumatology clinic with pain and swelling in the lower limb joints for last 4 years. He was initially experiencing pain in bilateral hip, with later involvement of knees and ankles. The patient simultaneously developed low back ache, which was worse in the early morning. The pain was more in the low back and towards right side. From the past 2 years, he was having difficulty and pain while getting up from sitting position and in climbing the stairs. However, no upper limb symptoms were reported. He had lost 2 kgs in the past 3 months.
He used to have episodes of urticarial rashes involving both upper and lower limbs. The rashes used to fade in 12-24 hours without leaving any scar. The patient had minimal dandruff and hair loss. He used glasses to correct both long and short visions and was advised to be on regular eye drops after diagnosing dry eyes around 3 years back. No dry mouth was complained.
He was diagnosed with hypertension and diabetes 12 and 15 yrs back respectively. He was on regular treatment and as per the medical records, he could achieve reasonably good control over both the conditions. The patient had undergone coronary artery bypass graft (CABG) surgery around four years back after an episode of infarction (since, the angiogram showed triple vessel disease).
For the past 4 years, he was on aspirin 150 mg, atorvastatin 10 mg, and metformin 500 mg twice daily. Carvodil, telmisartan and hydrochlorothiazide, with minor adjustment in the dosage, were also used.
Tender and moderately swollen knee and ankle joints were seen on physical examination. He had grade 3 or 4 weakness in the thighs. There was CABG scar on chest and systemic examinations were otherwise normal. Results of diverse parameter estimation conducted during the first visit are given in table 1.