47 Year old female patient with fever and joint pains ( short case)

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

H no : 1701006072

A 47 year old female tailor by occupation resident of nalgonda came to the OPD on 2_06_2022 with the chief complaints of 

Fever since 3 months

Facial rash from  15 days

History of presenting illness: 

Patient apparently asymptomatic 10 years back later she developed joint pains (in ankle and knee) it was associated with morning stiffness and limitation of joint movement . This get usually relieved after some activity .

For joint pains she went to local hospital where she tested RA positive

She was on diclofenac for 2 months and symptoms relieved

Last year she took COVID vaccination

Later she developed joint pains

After which she consulted orthopaedician  and symptoms relieved by taking medication

3months back  she  had joint pains and  fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. 

She went to the private hospital but the fever was recurrent associated with abdominal pain came here on 2/6/22

Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds and it developed from last 15 days

Past history

Patient had an history of gradual painless loss of vision since 2011and was certified as blind  2 years back

Not a known case of diabetes asthma Epilepsy thyroid tuberculosis and coronary artery disease. 

No similar complaints in the family

Personal history

DIET- mixed

Appetite: Normal

Bowel and bladder movements are regular

Sleep: Adequate

No known addictions and allergies.

General examination

Pateint is consious coherent co operative well oriented to time place and person,moderately built and moderately nourished and is examined with informed consent.

Pallor: present 

No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS

PULSE :86BPM

BP:120/80mm hg

RR:16cpm

SPO2:98%at room air

Local examination

Erythematous rashes seen bilaterally around cheeks

And it is insidious onset  and gradually subsided

 

A swelling seen on lateral aspect of left leg just above the ankle joint associated with itching , theombong type of pain and redness

Later pigmentation seen .

SYSTEMIC EXAMINATION 

CVS

Inspection:SHAPE OF THE CHEST IS NORMAL

no visible neck veins

No rise in JVP

No visible pulsation scars.

Palpation

ALL inspectory findings are confirmed 

Cardiac impulse felt at 5ty intercostal space 1cm medial to the mid clavicular line.

Percussion shows normal heart borders

Auscultation: s1 s2 heard no  murmurs

CNS 

Higher mental function normal 

Cranial nerve examination normal 

Normal motar and sensory system on examination

Respiratory examination

 Inspection

Shape of chest is elliptical, 

B/L symmetrical chest,

Trachea in central position,

Expansion of chest- normal on both sides

Palpation

All inspectory findings are confirmed,

No tenderness, No local rise of temperature,

Percussion

normal resonant note present bilaterally 

auscultation: normal vesicular breath sounds heard 

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:

CBP

• Hemoglobin- 6 gm/dl 
• PCV- 21 % 
• TLC- 8200/ cumm 
• RBC- 2.5 million/cumm 
• Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L  (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

INVESTIGATIONS:

CBP

• Hemoglobin- 6 gm/dl 
• PCV- 21 % 
• TLC- 8200/ cumm 
• RBC- 2.5 million/cumm 
• Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L  (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

XRAY

Chest x ray pA view

Ophthalmology report 

Bilateral optic atrophy 

Treatment given 

PROVISIONAL DIAGNOSIS:

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY.