FINAL EXAM- SHORT CASE

 47 Year old female patient with fever and joint pains ( short case)

June 09, 2022

This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

.

I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.        

H no : 1701006076

A 47 year old female tailor by occupation resident of nalgonda came to the OPD on 2_06_2022 with the chief complaints of 

Fever since 3 months

Facial rash from 15 days

TIME LINE OF EVENTS : 

                

             DIMINISION OF VISION since 20months

            COVID vaccination in aug 2021 

             Post vaccination joint pains.  

            Consulted orthopedic doctor in Nov 2021

            Symptoms relieved 

            Fever ( March 2022)

            Joint pain 

            Rash

History of presenting illness: 

Patient apparently asymptomatic 10 years back later she developed joint pains (in ankle and knee) it was associated with morning stiffness and limitation of joint movement . This get usually relieved after some activity .

For joint pains she went to local hospital where she tested RA positive.symptoms relieved on medication (diclofenac)

Last year she took COVID vaccination.

Later she developed joint pains

After which she consulted orthopaedician and symptoms relieved by taking medication

3months back she had joint pains and fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. 

She went to the private hospital but the fever was recurrent associated with abdominal pain came here on 2/6/22

Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds and it developed from last 15 days

Past history:

Patient had an history of gradual painless loss of vision since 2011and was certified as blind 2 years back

Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease. 

Family history:

No similar complaints in the family

Personal history

DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: Adequate

No known addictions and allergies.

General examination

Pateint is consious ,coherent ,co operative well oriented to time place and person,moderately built and moderately nourished and is examined with informed consent.

Pallor: present 

No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS

PULSE :86BPM

BP:120/80mm hg

RR:16cpm

SPO2:98%at room air

LOCAL EXAMINATION :

Erythematous rashes seen bilaterally around cheeks and nd it is insidious onset and gradually subsided

 A swelling seen on lateral aspect of left lower limb just above the ankle joint associated with itching ,redness, throbbing type of pain& non radiating .

Later pigmentation seen .

SYSTEMIC EXAMINATION

CVS examination: 

Inspection:SHAPE OF THE CHEST IS NORMAL

no visible neck veins

No rise in JVP

No visible pulsation scars.

Palpation:

ALL inspectory findings are confirmed 

Cardiac impulse felt at 5th intercostal space 1cm medial to the mid clavicular line.

Percussion shows normal heart borders

Auscultation: s1 s2 heard no murmurs

CNS examination:

Higher mental function normal 

Cranial nerve examination normal 

Normal motar and sensory system on examination

Respiratory examination:

 Inspection

Shape of chest is elliptical, 

B/L symmetrical chest,

Trachea in central position,

Expansion of chest- normal on both sides

Palpation

All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

Percussion

normal resonant note present bilaterally 

auscultation: normal vesicular breath sounds heard 

GIT 

inspection- normal scaphoid abdomen with no pulsations and scars

palpation - inspectory findings are confirmed

no organomegaly, non tender and soft 

percussion- normal resonant note present, liver border normal

auscultation-normal abdominal sounds heard, no bruit present 

INVESTIGATIONS:

CBP

Hemoglobin- 6 gm/dl 

PCV- 21 % 

TLC- 8200/ cumm 

RBC- 2.5 million/cumm 

Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

Rheumatoid factor positive 

Anti Ro antibodies - positive

LFT

Total bilirubin- 0.61 mg/dl (N)

Direct bilirubin- 0.16 mg/dl (N)

SGPT- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

XRAY

Ophthalmology report :

Bilateral optic atrophy 

PROVISIONAL DIAGNOSIS:

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY

Treatment given :

1.INJ PIPTAZ 4.5 gm IV/ TID.

2.INJ METROGEL100 ML IV/TID

3.INJ NEOMOL1GM/IV/SOS

4.TAB CHYMORAL FORATE PO/TID

5.TAB PAN 40 MG PO/ OD.

6.TAB TECZINE10 MG PO/OD

7.TAB OROFERPO/OD.

8.TAB HIFENAC-P PO/OD

9.HYDROCOTISONE cream 1%on face for 1week.