45 YR OLD FEMALE WITH RASH

7/6/2022

G Meghana 

1701006058

Final mbbs practical 

Short case :- 

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CASE:-

A 45 year old female , tailor by occupation came to the hospital with 

Chief complaints:- 

 

- On and off fever with generalized body pain since 3 months 

- loss of appetite since 3 months 

- itchy facial rash since 5-6 days 

History of Presenting Illness:-

- Patient was apparently asymptomatic 10 years back when she devedoped joint pain which was gradual in onset and of fleeting type which was associated with morning stiffness which usually used to last for 10 mins and was not associated with swelling .

- Patient went to some private hospital where she was treated for the same for two months and found to be RA positive . 

-- Patient remained asymptomatic after being treated and since 8 months back when she developed joint pain in the metacrpophalangeal joint and knee joint following injection of 1st dose of covishield . She was treated with Inj. Diclofenac for 5-6 days and pain releived in 20 days . 

- One month back patient had an episode of loss of consciousness with cold peripheries and sweating after taking Tablet Glimi M2 prescribed by the doctor for her high sugar level ( around 250 mg /dL ) .

-  10 days back patient developed fever and abdominal pain for which she was treated at a private hospital .

- Later she developed an erythematous rash over the face which was associated with itching ( increased on sun exposure)

Lesion was describe as diffuse erythematous and hyperpigmented papules and pustules were noted over the bilateral cheeck sparing the nasolabial fold . ( Drug rash ? )

* Swelling of the left leg over the lateral aspect with erythema and local rise of temperature (? Cellulitis )

- loss of weight since 2 months 

Past History :

* Patient had a history of diminution of vision at age of 15 years started using spectacles but there was gradual, progressive, painless loss of vision was diagnosed as Optic atrophy with macular degeneration . 

- Not a known case of DM , asthma , TB , COPD , epilepsy .

- No relevant drug, trauma history present.

- No similar complaint in the past 

Personal History :

 Diet- mixed

Appetite- decreased

Bowel and bladder- regular

Sleep- disturbed

Addictions- nil

Family History :

 Patient's sister had a similar history of joint pain in the past .

GENERAL EXAMINATION :

-- Patient is examined in a well lit room with adequate exposure, after taking the consent of the patient.

-- she is conscious, coherent and cooperative, thinely built and nourished.

Pallor +

no icterus 

 No cyanosis

 No clubbing 

no lymphadenopathy 

No edema.

VITALS:

Patient was afebrile at the time of presentation .

BP: 110/70 mmHg 

PR: 72bpm regular and normal                    volume,felt bilaterally

RR:18 cpm

SpO2 : 98 with RA

LOCAL EXAMINATION:

left lower limb swelling was present at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt

The erythematous rash was present on the face sparing the nasolabial fold?malar rash 

SYSTEMIC EXAMINATION:-

CVS:

- inspection shows no scars on the chest, - - no features of raised JVP, no additional visible pulsations seen

-- all inspectory findings are confirmed

Palpation:-

-- apex beat normal at 5th ics medial to mcl

-- no additional palpable pulsations or murmurs

Percussion:-

-- showed normal heart borders

auscultation:- S1 S2 heard no murmurs or additional sounds

RESPIRATORY:

inspection: normal chest shape bilaterally symmetrical, mediastinum central

no scars, Rr normal, no pulsations

palpation: Insp findings are confirmed 

percussion

: normal resonant note present bilaterally 

CNS: C/C/C

MOTOR-: normal tone and power 

reflexes: RT         LT

BICEPS ++            ++

TRICEPS ++.          ++

SUPINATOR ++      ++

KNEE ++                   ++

SENSORY :

touch, pressure, vibration, and proprioception are normal in all limbs

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:-

B/l minimal pleural effusion with basal lung consolidation

USG ABDOMEN:-

heptomegaly with grade 2 fatty liver 

B/l minimal pleural effusion with basalung consolidation

 

--Raised RA factor

-- LFT :-Raised SGPT and SGOT 

Hematology report:- 

Normocytic hypochromic ( Hb 6.0 )

Mild decrease in Platelet count 

Relative monocytosis 

Overall Investigations :

RBS: 136mg/dl

HEMOGRAM:

HB: 6.9

TC: 9700

MCV: 85.1

PCV: 21.7

MCH: 27.1

MCHC: 31.8

PLT: 1.57

ESR: 90

SMEAR: ANISOCYTOSIS

RFT:

Blood Urea: 20mg/dl

S. Creatinine: 1.1mg/dl

Na: 136

K: 3.3

Cl: 98

LFT:

TB: 0.45

DB: 0.17

AST: 60

ALT: 17

ALP: 138

CUE:

ALB +

Sugars nil

Pus cells nil

ESR - 90

CRP - negative 

HCV: Negative 

HBV: Negative 

HIV: negative 

Shirmer test : Investigation of choice

ANA report 

PROVISIONAL DIAGNOSIS: 

? Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L optic atrophy 

Treatment history :-

On 1st day ( 02/06/22 )

Inj. Piptaz 4.5 gm / iv / tid 

Inj. Metrogyl 600 mL /iv / tid 

Inj. Neonol 1 gm /iv / SOS ( if temp more than 101 F )

Tab. Chymoral forte PO/ TID 

Tab Pan 40/ PO/ OD 

Tab teczime 10 mg / PO/ OD

Hydrocortisone cream 1 per cent / OD face * week

Tab Orofer XT / OD

Inj. Nervz 1 amp in 100 mL NS 

Above treatment repeated for 4 days and patient was discharged in 7/6/2022