CASE-2;- JOINT PAINS , MALAR RASH , ORAL ULCER

 This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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

CASE

A 36 years old female patient with chief complaints of  Multi-Joint pain since 2 months, Morning stiffness of joints since 1 month, Menorrhagia since 1 month.

HOPI

Patient was apparently asymptomatic 2 months back. Then she started rapidly gaining weight, Menorrhagia , Multi-Joint pains for which the visited a Hospital . 

They found that her TSH was > 100 mIU/L. ( Normal Range :- 0.5 to 5.0 mIU/L). So, She was started on THYRONOME 100 mcg.

After which her menorrhagia subsided, but she continued to have multiple-joint pain ( all small joints and large joints) associated with swelling of joints, Morning stiffness for 30mins, on evaluation she was found to have CRP (+) , Hb-10.8gm?dl , Uric acid-7.8 and was started on  Tab. ALLOPURINOL 100mg/BD.

Her Joint pains associated with ON & OFF low grade fever since 2 months, using Tab. PCM 650mg BD since 2 months.

On Dec. 29th:

ANA- 3.18 (IF >1.2 Strongly positive)

Anti CCP- 1.4 UI/ml (Negative)

Rh factor - Negative 

TSH- 16.9 (continued on Tab. THYRONOME 100 mcg)

since 5 days Patients complaints that her joint pains and swelling subsided.

Patient C/O oral ulcers since 20 days

Patient C/O Blackish spots over malar aspect of face since 15days.

MRI spine done on 3/1/2022 - Multiple level disc protusion causing thecal sac indentation and B/L   C5-C6 mild neural foraminal stenosis.

PAST HISTORY 

K/C/O Hypothyroidism (on T.THYRONORM 100 micrograms)

N/K/C/O DM, HTN, CAD

No previous hospitalisation

GENERAL EXAMINATION

• Patient is C/C/C.
• · Pallor : Yes
  
• · Icterus: No
  
• · Cyanosis :no
  
• · Clubbing of fingers/toes : Yes
  
• · Lymphadenopathy : No 
  
• · Edema of feet : No
  
• · Malnutrition : No
  
• · Dehydration : No
  
• · Temp. : 99.6 F
  
• · P.R.  : 120 bpm
  
• · R.R. :  21 cpm
  
• · B.P.   :  110/80 mmhg
• · SPO2 at room Air : 98%

SYSTEMIC EXAMINATION

C.V.S

• · Cardiac sounds      :- S1 & S2 - Present
• · Cardiac murmurs   :- NO 

RESP. SYSTEM

• Dyspnoea  :NO
• Wheeze    :Expiratory wheeze Absent in all areas.
• Position of Trachea : Central
• Breadth Sounds : Vesicular

ABDOMEN

· Shape of abdomen : Normal

· Tenderness : NO

· Palpable Mass : NO

· Liver : Not Palpable

· Bowel sounds: Yes

C.N.S

· Level of consciousness : Consciousness: Conscious / Alert 
· Speech : Normal
· Signs of Meningeal irritation   
a)Neck stuffiness: NO  b)Kernig's sign: NO
· Cranial nerves- Normal
· Motor system - Normal
· Sensory nerves- Normal

INVESTIGATIONS

CLINICAl IMAGES 

PROVISIONAL DIAGNOSIS 

Sero-negative arthritis (2° to RA ?SLE) with k/c/o hypothyroidism 

TREATMENT 

• TAB.THYRONORM 100mcg po od bbf
• Syp. MUCAINE GEL 10ml po tid
• TAB. RIBOFLAVIN 5mg po bd
• TAB. ZINCOVIT po od
• TAB. PCM 650mg po sos
• TAB. PAN 40mg po od
• ZYNTEE gel for l/a
• INJ. NEOMOL 1g iv sos (if temp >100°F)
• TAB. ULTRACET 1/2 tab qid
• TAB. WYSLONE 40mg po od

Temp/BP/PR/SPO2 monitoring 4th hrly