A 31 YEAR OLD WOMEN WITH HIGH GRADE FEVER AND JOINT PAINS

SUDHAMSHI REDDY M

MBBS 9th semester

Roll no:80

This is 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 patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

I’ve 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 .

31 year old female, who studied till degree and is a housewife by occupation came with chief complaints of:

B/L knee pains since 2 weeks
Fever on and off since 2 weeks
Oral ulcers since 6 months

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years ago (March 2020)

Then developed pain in her right shoulder because of which she could not raise her hand above her shoulders.

It was dull aching type and continuous, for which she went to an Orthopaedic and was given medication.

The pain kept alternating between right and left shoulder and sometimes both simultaneously. She then experienced tightness of shoulder joints on waking up and needed someone to pull her up from the bed.

Her pain was relieved on medication but it kept recurring for 6 months.

1 month later she noticed swelling in proximal interphalangeal joints, it was associated with decreased function as she was not able to write properly, open bottle cap etc.

She also developed B/L knee pains and generalized weakness.

Then she developed fever, oral ulcers , redness of eyes and diminished vision, facial puffiness and went to a private hospital.

She also developed hair loss 2 years ago, which was gradually progressive.

On routine investigations, nephrotic range proteinuria was detected in her urine sample, increased protein creatinine ratio of 4.99 due to which they decided to a kidney biopsy.

BIOPSY FINDINGS: focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS

ANA PROFILE: Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN

Based on this the diagnosis of SLE was made.

She was put on Tab. OMNOCORTIL 5mg for 3 days and steroid injections and was tapered over 6 months to 2.5mg.

After 6 months, steroids were stopped and was started on

Tab. MMF for 4 months (2 tab at 8 AM and 1 tab at 8 PM), which she used and stopped after one month after tapering. She was also advised to perform exercises.

In January 2022,

She was started on FOLITRAX after which she noticed increase in number of oral ulcers , so she went to a private hospital 15 days later, and was started again started on OMNOCORTIL 5m.

At present, the patient is complaining of

B/L knee pains since 2 weeks, aggravated since 3 last three days, associated with difficulty in walking and getting up from sitting posture.

Pain is more towards the morning.

Fever on and off since 2 weeks, low grade initially and progressive.It was not associated with chills or rigors. Relieved on taking medication.

Not associated with vomiting, diarrhoea, cough , cold.

Oral ulcer since 6 months, aggravated since last 3 months because of which she is unable to eat this resulting in weight loss of about 6 kgs in last 3 months.

There was no bleeding or discharge from the ulcer.

Pain in the epigastrium and left hypochondrium since last night, after eating.

Complained of 2 episodes of vomiting last night, watery consistency.

HISTORY OF PAST ILLNESS:

Patient is a known case of HYPOTHYROIDISM since 4 years and is on Thyronorm 50mcg .

Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA

PERSONAL HISTORY:

Appetite- normal

Diet -mixed

Sleep - adequate

Bowel and bladder- regular

No addictions, no known allergies for food or drugs.

MENSTRUAL HISTORY:

She bleeds for 3 days in a 30 day cycle

She uses 3 pads per day.

Recently, she complains of spotting 5 days before her first day of menses

MARITAL HISTORY:

She got married at age of 24years.

ANTENATAL HISTORY:

P3 L2 A1

In 2015, her first pregnancy reached full term and NVD was done.
She developed high grade fever in her 6th month, and was diagnosed with malaria.
She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication.

In 2019, her third pregnancy, reached full term and NVD was done.

FAMILY HISTORY:

No similar complaints in the family.

No significant family history.

SURGICAL HISTORY:

Cataract surgery in left eye in Jan 2022

TREATMENT HISTORY:

Patient is currently on:

Tab. MMF 500mg PO BD (8AM & 8 PM)
Tab. FOLITRAX 10mg weekly once
Tab. LIVOGEN PO BD
TAB. HCQ 200mg OD
Tab. SHELCAL PO OD
Tab. THYRONORM 50mcg

GENERAL EXAMINATION:

With consent taken from the patient and her husband in a written form, the patient was examined in a well lit room in supine as well as sitting position.

Patient is conscious, coherent and cooperative.

No signs of pallor, icterus, kolionychia, cyanosis, generalized lymphadenopathy, and edema.

VITALS:

Temperature: 102 degrees F

Blood Pressure: 110/70

Pulse Rate: 99 bpm

Respiratory Rate: 18 cpm

29/3/2022

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

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.

Apical Impulse is not appreciated

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 – scaphoid

Flanks – free

Umbilicus –central in position , inverted.

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

PERCUSSION:

There is no fluid thrill , shifting dullness.

Percussion over abdomen- tympanic note heard.

AUSCULTATION:

Bowel sounds are heard.

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, vibration sense) are

INVESTIGATIONS

HEMOGRAM:

Hemoglobin: 9.3

TLC: 3500

N/L/E/M: 78/15/2/5

Platelet: 2.3

MCV:77

MCH:25.8

MCHC:33.5

RDW:15.5

CUE;

Albumin: Trace

Sugars: Nil

Pus Cells: 2-3

Epithelial cells: 2-3

APTT: 32 seconds

PT: 16 seconds

INR: 1.11

CRP: 0.6

ESR:55

RA FACTOR: negative

LFT;

TB:0.9

DB:0.2

SGOT:18

ALT:16

ALP:12.3

TP:6.3

ALB:3.16

A/G:1.01

RFT;

UREA:24

CREATININE:0.7

NA:138

K:4.1

Cl:105

USG REPORT:

ECG-

X- RAY Chest

PROVISIONAL DIAGNOSIS:

SYSTEMIC LUPUS ERYTHEMATOSIS - CLASS III LUPUS NEPHRITIS

WITH RHEUMATOID ARTHRITIS

WITH HYPOTHYROIDISM

WITH BILATERAL RETINAL VASCULITIS .

TREATMENT:

IVF NS RL @ 75ml/hr
Inj. NEOMOL 1 gm IV SOS
Tab. DOLO 650mg PO/QID
MUCOPAIN GEL for L/A over ulcers.
Tab. MMF 500mg PO BD (8AM & 8 PM)
Tab. FOLITRAX 10mg weekly once
Tab. LIVOGEN PO BD
TAB. HCQ 200mg OD
Tab. SHELCAL PO OD
Tab. THYRONORM 50mcg