short case 2

THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT 





Patient came to our hospital on January 15,2022 follow up case. 

30 years old female homemaker by occupation came to the General Medicine OPD with the 

January :  

- B/L joint pains (knees) since 10 months

     - B/L itching in the upper aspect of chest and neck since 10 months 

       

H/O P.I.: Patient was apparently asymptomatic 10 months ago. Then she developed symmetrical b/l joint pains in the knees which was insidious in onset, gradually progressive, no aggravating factors 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. As a result of the itching, the area was initially red and turned black. 



C/O Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.



C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.



C/O generalised pain.



C/O Difficulty in walking.

C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, combing of hair.

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

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

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

C/O weight loss of 4 kg over the last 10 months.

C/O oral ulcers and genital ulcers since 10 months.

-No h/o fever, cold, cough.

  During  March : 

        - B/L joint pains associated with edema over legs upto knee joint  including dorsum of foot since 4 days

- c/o dyspnea at rest since 4 days

-c/o cough since 4 days
   
        

H/O P.I.: Patient was apparently asymptomatic 12 months ago. 

 Then she developed symmetrical b/l joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors 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. As a result of the itching, the area was initially red and turned black. 



C/O Alopecia since 12 months. It was gradually progressive leading to severe hair loss over the past 12 months. Associated with thinning of hair.
 

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

No history of distal muscle weakness manifested in the form of : 

No history of difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt,

-h/O Dyspnea on exertion (NYHA- 3), gradually progressive since 6 m

-she visited many local RMPs,received pain killers as there is no improvement, she visited a health centre 2 months back.

Following are the clinical images when she visited health centre 4 months back:





Her X RAYS 2 MONTHS BACK:









Treatment given 2 months back:

And 1.tab.wysolone 50mg po od

2.syp.mucaine 10ml/po/tid

3.tab.ultracet 1/2 po/QIT

4.candid cream for L/A is advised



Patient was referred to other health centre for muscle biopsy.

Patient went to health centre,
her ANTI NUCLEAR ANTIBODY IMMUNOFLUORESCENCE showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA, antihistones.


MYOSITIS PROFILE was done which showed MDA-5 , PL-7, Ro -52 all three were strong positive



HRCT WAS DONE ON 21/1/22

IMPRESSION: Few patchy areas of ground glass opacities in peri brochovascular distribution-s/o pneumonitis .Corads-4

She didn't undergo muscle biopsy as the doctors there advised it is not necessary 


THEY PRESCRIBED:

1.TAB.CALTEN

2.TAB.AUGMENTIN

3.TAB.NAPROXEN SODIUM

4.TAB.FOLVITE

5.CANDID CREAM

6.TAB.WYSOLONE

7.TAB.ESOMEPRAZOLE


8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.



Past history: 


Not a k/c/o DM, HTN, BA, epilepsy, Asthma, CVA, CAD.

                 Had similar complaints in the past 2 months.

Menstrual h/o: AOM- 11 years


                3/25-28, regular , no pains, no clots.



Marital h/o: ML- 14 years, NCM

                 Primary infertility (Nulligravida) 

Has recently adopted a girl from her sister-in-law. 



Family h/o: No similar complaints in the family 



Personal h/o: 

            Diet- Mixed

           Appetite- Decreased

           Sleep- Inadequate since 12 months. WAKES AT 2 AM -3AM BECAUSE OF PAIN IN LEGS.

           Bowel and bladder habits- IRREGULAR

C/O LOOSE STOOLS FOR 4 DAYS FOLLOWED BY CONSTIPATION FOR 3 DAYS SINCE 8 MONTHS


           No addictions

           No known drug allergies 



General physical examination: The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished. 
 Skin lesions present


Pallor- present

No icterus, cyanosis, clubbing, lymphadenopathy.


Pedal Edema- present 



O/E:

Patient images after treatment of 2 months:






Vitals: 

Temperature- Afebrile

BP- 120/80 mm Hg

PR- 86bpm

RR- 18cpm

SpO2-98 on RA



SYSTEMIC EXAMINATION:


CNS : 

HMF- patient conscious
        oriented to place/time/person
no h/o aphsia/dysarthria
no h/o dysphonia
no h/o memory loss
no h/o emotional lability
MMSE- 30
cranial nerves- intact
MOTOR SYSTEM 
                                              Right.         Left
Bulk:     Normal
Tone:               ul.            normal.         Normal
                         LL.         normal           Normal
Power    
                   RT.          Lt 
Deltoid       4/5         3/5
Supraspinatus. 4/5.        3/5 
Infraspinatus.   4/5.    3/5 
Rhomboid.        3/5.  3/5 
Serratus anterior 4/5 3/5
Pectoralis major.   3/5. 3/5 
Latismus dorsi.    4/5.  4/5 
Biceps     5 /5     5/5
Triceps     5/5.   4/5 
Brachio radialis    5/5 5/5 

               
               iliopsoas                5/5.              5/5
   adductor femoris            4/5.               4/5
       gluteus medius             3/5.               3/5
   gluteus maximus            3/5.               3/5
              hamstrings            3/5.               3/5
quadriceps femoris            3/5.               3/5
tibialis anterior.                   5/5.               5/5
tibialis posterior.                 5/5.               5/5

Reflexes.  
   Superficial reflexes
                       Right.           Left
Corneal.            P                  P
Conjunctival    P.                  P
Abdominal.      +               +
Plantar            flexor.    Flexor

    Deep tendon reflexes 
                     Right.             Left
Biceps.          ++                 ++
Triceps.         +                 +
Supinator.     +                    +
Knee              ++                 ++
Ankle.            +                  +
 
SENSORY SYSTEM 
                                    RIGHT.           LEFT
SPINOTHALAMIC 
             crude touch.   N.                   N
                 pain.             N.                   N
            temperature.   N.                   N
post:
             fine touch.      N.                   N
             vibration.        N.                   N
     position sensor.    N.                   N
 cortical 
 2 point discrimination  N.                   N
tactile localisation.        N.                   N

CEREBELLUM
titubation - absent
ataxia - absent
hypotonia.         Absent

CVS- S1, S2 sounds heard. No murmurs

RS- BAE+ NVBS heard


P/A- Soft, non tender, Bowel sounds heard







INVESTIGATIONS- 
Chest X RAY-

ECG:

 USG ABDOMEN ON 15/3/22-
IMPRESSION: RIGHT RENAL CORTICAL CYST WITH WALL CALCIFICATION. 

2D ECHO ON 15/3/22
EF-60%
TRIVIAL AR/MR
GOOD LV SYSTOLIC FUNCTION 
NO DIASTOLIC DYSFUNCTION. 














































Sputum culture-presence of branching and filamentous acid fast bacilli are seen 
?Nocardia species 

HEMOGRAM

HB-9.9

TLC-9600

N/L/M/E-90/6/2/2

PLT-1.77

PCV-29.2

RBC-3.56

SERUM CREATININE-0.9

Na-137,k-3.5,Cl-98

LFT:TB-0.82,DB-0.24,AST-16,ALT

18,ALP-137,ALB-2,A/G: 0.62

GRBS-240MG/DL(8 AM)



Spot urine protein -27

Spot urine creatinine-19

Spot urine creatinineratio-1.42

PT-16 sec

APTT-32 sec

INR-1.11

24 hour urinary protein:59.9 mg/dl

24 hour urinary creatinine:0.5g/day



DERMATOMYOSITIS  with pulmonary Nocardiosis. (Resolving)
With mild  proximal myopathy?




















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