30 year old female with joint pains

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30  year old female came to the op with

*Chief complaints of:-

•Bilateral joint pains in upper and lower limbs(knees, hip, ankle, shoulder, elbow, wrist, including small joints) since 10 months. 

•Itchy lesions over the face,upper aspect of the chest, neck and back of the neck and upper trunk with dark coloured lesions over the knuckles since 10 months.

 •Generalised weakness since 10 months - Inability to comb the hair, difficulty in walking and inability to sit down. 

History Of present illness:-

•Patient was apparently asymptomatic 10 months back after which she developed bilateral symmetrical multiple joint pains involving all joints and it's severe in the knees which was insidious in onset, gradually progressive, aggravated on walking and relieved on medication i.e.tab.HYDROXYCHLOROQUINE 200 mg

•Associated with morning stiffness. 

•Around the same time she developed itching over neck and upper chest area.The area was initially red and turned black due to itching.

•H/o Dark coloured skin lesions over the knuckles 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. 

•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, combing of hair.

•H/o proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

•H/o weight loss of 4-5 kgs over the last 10 months.

•H/o vaginal discharge since 7-8 months. It was initially curdy white discharge which later changed to watery discharge. Associated with itching.

•H/o Genital ulcers on and off since 7 months.

•Dyspnea on exertion (NYHA- 3),gradually progressive since 4-5 months.

•No h/o fever, cold, cough.

Past History:-

 •No similar complaints in the past. 

 •Not a k/c/o DM, HTN,TB, epilepsy, Asthma, 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

*Personal History:-

       •Diet- Mixed 

       •Appetite- Decreased 

       •Sleep- Inadequate since 10 months

       •Bowel and bladder habits- Regular

       •No addictions

       •No known drug allergies 

Family History:-  •Not significant

*General Examination:-

         •Patient is conscious, coherent and cooperative.Well Oriented to time, place and person.

 •She is moderately built and moderately nourished.

 •Pallor- Present

  •Icterus-Absent

  •cyanosis-Absent

  •clubbing-Absent

  •lymphadenopathy-Absent

  •Pedal Edema- Present

 

On Examination:-

•Diffuse mottled erythematous hyperpigmentation (Heliotrope rash) noted on B/L cheeks, nose(bridge) involving nasolabial folds, ears, 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

Vitals:-

•Temperature- Afebrile

•BP- 130/80 mm Hg

•PR- 102 bpm

•RR- 14 cpm

•SpO2- 99% @ RA

Systemic Examination:-

CENTRAL NERVOUS SYSTEM EXAMINATION.

HIGHER MENTAL FUNCTIONS:

 Patient is Conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

                           Right. Left

BULK 

Upper limbs.         N. N

Lower limbs.         N. N

TONE

 Upper limbs.        N. N

 Lower limbs.        N. N

POWER

 Upper limbs.       5/5. 5/5

 Lower limbs        5/5. 5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position) are well appreciated

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

RESPIRATORY SYSTEM:-

INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 

PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all resonant 

AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard

ABDOMEN EXAMINATION

INSPECTION:

Shape – normal 

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving with respiration.

No dilated veins, hernial orifices , sinuses

No visible pulsations

PALPATION:

Soft, non tender

Spleen liver kidney not palpable

PERCUSSION:

There is no fluid thrill , shifting dullness

AUSCULTATION:Bowel sounds are heard

Provisional diagnosis:-

Dermatomyositis with vaginal candidiasis 

Investigations:-

Haemogram 

Hb-10.6

Tlc-3500

Neutrophils-68

Lymphocytes-20

Eosinophils-2

Basophils-0

Monocytes -10

Pcv-32

Mcv-80.8

Mch-26.8

Mchc-33.1

Platelet count-1.73

Impression:-Normocytic normochromic anemia with mild leucopenia 

Complete urine :---

Colour-pale yellow 

Appearance-clear

Reaction-acidic

Sp gravity-1.010

Albumin-nil

Sugar-nil

Bilepigments-nil

Bile salts-nil

Pus cells -2-4

Epithelial cells-1-2

Others-nil

Serum creatinine

Serum creatinine -0.6

Random blood sugar 

Rbs:-118mg/dl

Serum electrolytes

Sodium -139

Potassium -3.9

Chlorine-102

Esr -70

Esr is elevated

Serology- negative 

RA- negative 

Crp- negative

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