Medicine internal practicals
29 year old female with c/o joint pains since 10 months
29 YEARS OLD FEMALE WITH C/O JOINT PAINS and ITCHY SKIN LESIONS SINCE 10 MONTHS
•Bilateral joint pains in upper and lower limbs(knee joint, hip joint, ankle joint, metatarso phalyngeal joints, interphalyngeal joints of foot both distal and proximal, shoulder joint, elbow joint, wrist joint, metacarpo phalyngeal joints of hand, proximal and distal phalyngeal joints of hand.) since 10 months.
•Itchy dark coloured lesions over the face,upper aspect of the chest, front and back of the neck and back of trunk, along with dark coloured lesions over the knuckles and palmar aspect of interphalyngeal joints since 10 months.
•Generalised weakness since 10 months - Inability to comb hair, difficulty in walking and inability to sit down due to severe joint pains.
*History Of present illness:-
She is house wife. Daily, she wakes up at around 5AM in the morning, finish her namaaz and will do her house hold work and she sleeps at around 9PM
•Patient was apparently asymptomatic 10 months ago after which she developed bilateral symmetrical multiple joint pains involving proximal and distal interphalyngeal joints of both upper and lower limbs and it is severe in the knee joints which was insidious in onset, gradually progressive, pricking type of pain ,aggravated on walking and relieved on rest and medication i.e.tab.HYDROXYCHLOROQUINE 200 mg
joint pains initially started in knee joints -->then ankle joints --> metatarso interphalyngeal joints --> DIP and PIP joints of feet --> hip joint-->shoulder joints-->elbow joints-->metacarpo phalyngeal joints -->DIP and PIP joints of hand .
Associated with morning stiffness and fever (temperature rises in the evening).
•Around the same time she developed itching over neck front and back and upper chest area.The area was initially red due to itching and later turned into black colour after few days. She also developed itchy lesions over face at the same time.
•H/o Dark coloured And erythematous skin lesions over the knuckles and palmar surface of interphalyngeal joints since 10 months
•H/o photosensitivity present (Itching increases on sun exposure)
•H/o Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.
•H/o bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.
•H/o generalised weakness since 10 months.
10months back she went to a local hospital there she was give medications for joint pains.
•H/o Dfficulty in walking and difficulty to sit down.
•H/o distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, dressing and undressing
•H/o proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height., combing of hair.
•H/o weight loss of 4-5 kgs over the last 10 months.
•H/o Oral ulcers on and off since 10 months.
•H/o vaginal discharge since 7-8 months. It was initially curdy white discharge till 6months which later changed to watery discharge in the last 2months. Associated with itching.
•H/o Genital ulcers on and off since 7 months.
•Dyspnea on exertion (NYHA- 3),gradually progressive since 4-5 months.
Itching and redness present on flexor surface of arm and forearm since 1month.
*Past History:-
•No similar complaints in the past.
•Not a k/c/o DM, HTN,TB, epilepsy, Asthma, CVA, CAD.
*Menstrual History:-
•Age of menarche:-11 years
•Duration of cycle :- 3/28 days
•Regular cycle with no pains and no clots.
*Marital History:-
•Age at marriage:19years
•Non consanguinous marriage
•Primary infertility (Nulligravida)
*Personal History:-
•Diet- Mixed
•Appetite- normal but she is unable to eat properly due to on and off oral ulcers since 10months
•Sleep- Inadequate since 10 months
•Bowel and bladder habits- Regular
•No addictions
•No known drug allergies
*Family History
•No similar complaints were present in their family.
*General Examination:-
•Patient is conscious, coherent and cooperative.Well Oriented to time, place and person.
•She is moderately built and moderately nourished.
•Pallor- Absent
Icterus-Absent
•cyanosis-Absent
•clubbing-Absent
•lymphadenopathy-Absent
•Pedal Edema- Present Bilaterally pitting type
*On Examination:-
- Diffuse mottled erythematous hyperpigmentation noted on B/L cheeks, nose(bridge) involving nasolabial folds, neck extending onto upper chest and back forming a ‘V’ on anterior chest (Shawl sign)and 'V' sign.
Single erythematous macule noted over the right loin (Holseir sign).
Pigmentation of B/L extensor surfaces of PIP and DIP noted (Gottron's papules).
Mottled erythematous lesions on the palms(DIP and PIP joints)
JOINTS. TENDERNESS RESTRICTION OF MOVEMENTS
Neck(atlanto --- ---
axial joint)
Shoulder + ---
Elbow + ---
Wrist + +
Metacarpo
phalyngeal joints
1st + ---
2nd + ---
3rd . --- ---
4th. + ---
5th. + ---
Interphalyngeal
joints
PIP
Thumb + +
2nd + ---
3rd. --- ---
4th. + +
5th. --- ---
DIP
2nd . --- ---
3rd. + ---
4th. + ---
5th + ---
Hip(only + ---
In right hip joint)
Knee . + +
Ankle + ---
Metatarso
phalangeal joints
1st + ---
2nd + ---
3rd + ---
4th + ---
5th + ---
All Inter
phalangeal joints
of the feet. + +
There are no swellings and deformities in upper and lower limb joints
Restriction of movement in knee joint
Popliteal fossa not touching the surface and pain is present on foreceful extension.
Dip is absent between the interphalyngeal joints of feet.
*Vitals:-
•Temperature- 99F
•BP- 130/80 mm Hg
•PR- 85 bpm
•RR- 14 cpm
•SpO2- 99% @ RA
*Systemic Examination:-
•CVS:-S1, S2 sounds heard. No murmurs
•RS:- BAE+ NVBS heard
•CNS:-NAD
•P/A:- Soft, non tender, Bowel sounds heard
*Investigations:-
•HEMOGRAM:
*Normocytic Normochromuc blood picture with MILD LEUCOPENIA.
•COMPLETE URINE EXAMINATION
•SERUM CREATININE:
•BLOOD SUGAR-RANDOM:-
•SERUM ELECTROLYTES:-
ESR:-
*ESR-Elevated.
•ECG:-
ULTRASOUND:-
*Cortical calcifications noted at upper pole of Rt.Kidney
*Raised Echogenicity of B/L Kidneys.
•SEROLOGY - Negative
•RA Factor- Negative
•CRP- Negative
*Provisional Diagnosis:-
Dermatomyositis with vaginal candidiasis
SLE under evaluation
*Referrals:-
•Dermatology referral was taken.
*Treatment:-
1.Tab.Fluconazole 150mg/PO/stat
2.Candid cream L/A
3.Tab pan 40 mg PO/OD
4.Tab Ultracet 1/2 tab/PO/Q.I.D
5.Syrup.Grilinctus BM 10ml/PO/T.I.D
6.Syrup.Mucaine Gel 10ml/PO/T.I.D
She was admitted on 08/01/2022
SOAP notes on day 2
S- No fresh complaints
O- Pt c/c/c
BP: 110/80 mmhg
PR: 86 bpm
CVS: S1 S2 +
RS: BAE +
PA: soft, NT
A- ? DERMATOMYOSITIS
? SLE with VAGINAL CANDIDIASIS
P- T. FLUCONAZOLE 150 mg PO/OD
CANDID CREAM for L/A
T. PAN 40 mg PO/OD
T. ULTRACET 1/2 tab /PO/QID
SYP. GRILLINCTUS 10 ml PO/ TID
SYP. MUCAINE GEL 10 ml PO/ TID
SOAP notes on day 3
S- c/o b/l joint pains, itching in the upper aspect of chest and neck
O-
Pt is c/c/c
BP-120/80 mmHg
PR- 85bpm
CVS-S1S2+
RS-BAE+
P/A- soft,non tender
CNS- no fnd
A-
? DERMATOMYOSITIS
?SLE
? VAGINAL CANDIDIASIS
TREATMENT:-
1. T FLUCONAZOLE 150MG/PO/OD
2. CANDID CREAM FOR L/A
3. T PAN 40 MG PO/OD
4. T ULTRACET 1/2 TAB /PO/QID.
5. SYP GRILLINCTUS BM 10ML/PO/TID
6. SYP NUCAINE GEL 10ML/ PO/TID
SOAP notes on day 4
S: C/o b/l joint pains, itching in the upper aspect of chest and neck
O:
Pt is c/c/c
BP-120/80mmHg
PR- 82 bpm
CVS-S1S2+
RS-BAE+
P/A- soft,NT
CNS- no FND
A:
? DERMATOMYOSITIS
?SLE
with VAGINAL CANDIDIASIS
P:
1. T FLUCONAZOLE 150MG/PO/OD
2. CANDID CREAM FOR L/A
3. T PAN 40 MG PO/OD
4. T ULTRACET 1/2 TAB /PO/QID.
5. SYP GRILLINCTUS BM 10ML/PO/TID
6. SYP MUCAINE GEL 10ML/ PO/TID
