1. IN THE NAME OF GOD

2. A 46 Y/O MALE WITH FEVER AND WEIGHT LOSS

3. PI
46-year-old male patient trauma caused by lifting heavy objects with right shoulder rotator cuff tear is , One week after surgery, pain and severe swelling in both knees locked them and the difficulty in climbing stairs and inflation are both lower legs to ,One month after surgery the pain and restriction of movement both shoulders be, Weight loss up to eight to nine kilograms in two months and is accompanied by fever and night sweats mentioned above, but does not mention a history of erythema

4. PMH DM (-) HTN (-) IHD (-) HLP (-) Recurrent pneumonia(+)
Past surgical history (+)
recurrent Sinositis (+)
Diarrhea(+)

5. DH & Habits
tab pantazole 40 mg daily Tab acetaminophen ibuprofen Tab diclofenac sodium Smoking (-) Addiction (+)

6. PHYSICAL EXAM
V/S
BP: 125/80
PR: 90
RR: 16
T: 37

7. PHYSICAL EXAM HEAD & NEACK he is mentally alert Nl JVP LAP (-)
Eye redness (-)
Icter (-)
Butterfly rash (-)
Paleness of Conj (+)
Nasal flaring (-)
Oral ulcer (-)

8. PHYSICAL EXAM CHEST The lungs are clear in auscultation
Cardiac rhythm is normal without murmurs, extra sounds, or rubs

9. PHYSICAL EXAM ABDOMEN Rash (-) Soft
Tenderness & rebound tenderness (-)
Organomegaly (-)

10. PHYSICAL EXAM Extrimity Rash (-) Pitting Edema : (1+) Clubbing (-)
Thickening of the skin (-)
Palpable purpura (-)
Nl & symmetrical arterial pulses
ROM: decreased in shoulders pain of motion :+
Knee effusion + , ballotman +, FABER : NL Sacroiliac Tenderness:-
FORCE: NL
TONE : NL

11. PROBLEMS
Low grade fever
Weight loss
Recurrent infections
Arthritis

12. DDX collagen vascular disease Malignancy MM HIV INFECTIONS
immunodeficiency

13. WBC
8000
RBC
4600 Hb
11.9
HCT
37.3
MCV
81.1
MCH
25.9
MCHC
31.9
PLT
313000

14. BS 90
Urea 18 cr
0.7 Na
135 k
4.1 ca 9 p
4.4
Ast 19
Alt 23
Bilirubin direct
0.1
Bilirubin total
0.3
PTT 35 PT 12
INR 1
ESR
39 mm/h
CRP
positive

15. ANA
negative
Anti ds DNA
1.2 ( NORMAL < 25)
HIV Ab
Non reactive
HBS Ag
HBS Ab
Hcv Ab
PSA
0.7
CA19-9
17.8 (NORMAL <37 u/ml)
CEA
3.6 (NORMAL < 5.5ug /l )
IgA
17 ( NORMAL mg/dl)
IgG
3 ( NORMAL 700 – 1600 mg/dl )
IgM
2 ( NORMAL 40 – 230 mg/dl )

17. PROBLEMS Low grade fever Weight loss Recurrent infections Arthritis
Anemia
hypogammaglobulinemia

18. BMB & BMA
Megaloblastic changes in erythroid and myeloid series with the following diff:
Myeloid: 61%
Erythroid :29%
Lympoid : 7%
Blast :2 %
Plasma cell :1%
Iron storage :2+
Bone marrow biopsy findings: 70% cellularity whith no definit infiltration
Diagnosis : Hyper cellar marrow with megaloblastic changes

19. ENDOSCOPY AND BIOPSY
Sections show duodenal mucosal lined by columnar epithelium, the lamina properia show modrate infiltration of lymphocyte and few pmn leukocyte and eosinophils the granular components show regenerative changes, no evidence of malignancy is seen.
Diagnosis : moderate chronic inflammation

20. RIGHT SHOULDER MRI WITHOUT CONTRASR
There is focal abnormal signal at bursal side of supraspinatus tendone infavour of partial tear , fluid not in bursa, otherwise study is unremarkable

21. Whole body scan
Modrate and diffuse increased ratio tracer uptake is seen in humeral and femoral heads bilaterally and symmetrically suggestive of bone marrow reactive process (non specific), reminder of the skeleton is unremarkable except mild djd in knees

22. CXR: NL
CT SCAN OF LUNG : NL

23. Synovial fluid:
Wbc:12000
Rbc:3500
Pmn:88%
Lymph:10%
Monocyte:2%
Culture & crystal: (-)