Final practical short case

 

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45 Y/O female with fever and rash               

 A 45-year-old female tailor by occupation came to the hospital with chief complaints of fever on and off, associated with generalized body pains, loss of appetite for 3 months, facial rash since 10days.  

   HISTORY OF PRESENT ILLNESS:

 Patient was apparently asymptomatic 10 years back then she developed joint pains started first in the knees and ankles then slowly progressed to hands associated with swelling and morning stiffness for 10 min,and for this patient went to a private hospital and found RA factor positive and treated with diclifenac and patient was asymptomatic for 8 months 

 

Last year at around month of August patient took covid vaccination of one dose following which she developed post vaccination joint pains. 

In the month of November patient consulted orthopedic and was given medication and thus relieved from symptoms. 3months back then she developed fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. Relieved on medication . She went to the private hospital but the fever was recurrent associated with abdominal pain came here 5 days back.

1 month back patient had an episode of loss of consciousness associated with sweating after taking metformin tablet prescribed by local RMP 

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, following intake of unknown medication for abdominal pain

PAST HISTORY:-

Patient had an history of gradual painless loss of vision since 2011and was certified 

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- decreased

Bowel and bladder- regular

Sleep- disturbed

Addictions- nil

GENERAL EXAMINATION :

Patient is conscious coherent cooperative and well-oriented with time, place, and person 

moderately built and nourished

Pallor  - Present 

No icterus, clubbing, cyanosis, lymphadenopathy, and edema 

VITALS:

Patient was afebrile

BP: 110/70 mmhg,

PR: 78bpm,

RR:18 cpm

SP02: 98%

LOCAL EXAMINATION:

Swelling at ankle associated with redness and local rise of temperature and itching pigmentation and pain which is throbbing type non radiating no aggravating and relieving factors and dorsalis pedis pulses were felt

The erythematous rash is present on the face which is not associated with the itching but was there 10days back gradually subsided

SYSTEMIC EXAMINATION;

CVS:

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

all inspectory findings are confirmed

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

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

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 

Investigations:

PROVISIONAL DIAGNOSIS: 

Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L Optic atrophy

TREATMENT:

1.INJ PIPTAZ 4.5 gm IV/ TID.

2.INJ METROGEL100 ML IV/TID

3.INJ NEOMOL1GM/IV/SOS

4.TAB CHYMORAL FORATE PO/TID

5.TAB PAN 40 MG PO/ OD.

6.TAB TECZINE10 MG PO/OD

7.TAB OROFERPO/OD.

8.TAB HIFENAC-P PO/OD

9HYDROCOTISONE cream 1%on face for 1week.