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Investigations:
serum ACE (requested)
TFT (requested)
HLA-B27 (requested)
CRP (requested)
LFT (requested)
Bone Profile (requested)
ESR (requested)
Renal profile (requested)
Ig & electrophoresis (requested)
FBC (requested)
RF (requested)
Investigations:
CXR x-ray (requested)
Hips x-ray (requested)
LS-Spine x-ray (requested)
Plan and Recommendations:
Await investigations
Follow-up appointment
Assessment Summary:
Referral from GP with history of back pain and stiffness of acute onset since 15th December 2017 . This subsided somewhat in 3 to 5 days and was followed by pain and swelling left ankle that was closely followed by bilateral wrist and hand swellings as well as Rt Knee. These pain lasted approximately 3 to 5 days and no overlapping joint pains . The joint pains were followed by stiffness and moderate restriction in ROM . The initial symptoms were not associated with any Fever / Conjunctiva congestion / Urethral discharge / painful nodules / mucosal ulcers. He has long standing b/l sciatica for quite a few years. He works as a Tree Surgeon and has a fairly active lifestyle and healthy eating habits. Not a regular alcohol user. The only positive symptoms elicited are buttock pains that seem to be unrelated to the previous sciatica . The patient has some pictures of the joint swellings he has had and it seems likely that he has had synovitis as well. Dr Mo has seen him in the clinic and he has been advised XR LS Spine and Pelvis, XR Chest and blood serology including Immunoglobins and S ACE . We will review him in 6 weeks . No change in his current meds from GP as he seems well controlled with Naproxen.
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