Medicine Case Discussion
36 year old female patient with history of multiple joint pains , malar rash and oral ulcers
P.Manasa
9th semester
Roll no:- 102
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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
Case :-
A 36 year old lady resident of sripuram , home maker by occupation came to the opd with the cheif complaints of
* Multiple joint pains since 2months
* oral and tongue ulcers since 20 days
* small blackish spots over face since 15 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2months ago when she had fever , rapid weight gain ,multiple joint pains and menorrhagia.
PAIN
Insidious in onset
2months duration
Intermittent in nature
Involving large and small joints
Increased during morning and evening
associated with low grade fever
Relieved on rest and medications
*she visited hospital tested TSH more than 100 mIU/L and was started on tablet THYRONORM 100micrograms
Her menorrhagia subsided but she continued to have multiple joint pains and associted swelling , morning stiffness for 30 minutes.
On evaluation she was found to have CRP+ve, HB- 10gm/dl, uric acid 7.8 started on tab allopurinol 100mg BD
Past History:-
She had no history of similar complaints in the past
she is a known case of HYPOTHYROIDISM since 1 month
No history of Hypertension , Diabetes,Epilepsy, Cardiovascular diseases etc ..
No history of previous Hospitalization
MENSTRUAL HISTORY :-
Menstrual cycle - 28 days cycle
Duration 4days
Associated with pain
No.pads used - 3perday
Personal History:-
DIET - MIXED
APPETITE - NORMAL
BOWEL &BLADDER - REGULAR
SLEEP is disturbed
NO ADDICTIONS
NO H/O DRUG ALLERGIES.
Family History:-
No history of similar complaints in the family
GENERAL EXAMINATION
* Patient was examined in well light and good ventilation room after taking consent.
*Patient was conscious , coherent and co- operative.
* Moderately built and Moderately nourished.
Pallor - Present
No Icterus
No Cyanosis
No Clubbing
No Bilateral pedal oedema
No Lymphadenopathy.
Vitals Admission
Temperature = 98.6 F
Pulse rate = 115 beats permin
Respiratory rate = 20 cycles/min
Blood pressure = 110/70 mm of Hg
Spo2 = 99% at room air
GRBS = 89 mg/dl.
VITALS ON 06 .1 .2022
*Temperature = 98.4 F
Pulse rate =106beats permin
Respiratory rate = 22cycles permin
Blood pressure = 110/80 mm of Hg
Spo2 = 97% at room air
GRBS = 127mg/dl.
VITALS ON 07.1.2022
Temperature = 97.6 F
Pulse rate = 75beats permin
Respiratory rate = 21 cycles permin
Blood pressure = 110/70 mm of Hg
Spo2 = 98 % at room air
GRBS = 135 mg/dl
VITALS ON 08.1.2022
Temperature = 97.6 F
Pulse rate = 84beats permin
Respiratory rate = 16 cycles permin
Blood pressure = 120/80 mm of Hg
Spo2 = 98 % at room air
GRBS = 125 mg/dl
VITALS ON 09.1.2022
Temperature = 98.6 F
Pulse rate = 83beats permin
Respiratory rate = 16 cycles permin
Blood pressure = 120/80 mm of Hg
Spo2 = 98 % at room air
GRBS = 145 mg/dl
Temperature fever chart:-
SYSTEMIC EXAMINATION
* CVS - S1 , S2 sounds heard
No murmurs.
* Respiratory system
~Normal vesicular breath sounds heard
~ Bilateral air entry present (BAE+ve)
* Abdomen
soft and Non Tender
Bowel sounds normal
* CNS
No Neurological deficits are seen
No signs of meningial irritation
Gait - Normal
*Patient referred to DVL
1) Dark colored skin lesions over malar area since 6months
2) lesions over oral cavity since 15days
Diagnosis :- oral candidiasis + Me las ma
Treatment :- tab.fluconozole 150mg
Candid orapaste OD 1week
Provisional Diagnosis :-
Sero Negative Arthritis ,
secondary to SLE (ANA+ve)/ Rheumatoid Arthritis with K/C/O of Hypothyrodism
oral candiadisis and melasma.
INVESTIGATIONS:-
Hemogram:-
Ultrasound :-
Immunology - serology
Chest xray
TREATMENT HISTORY
On 05.1.2022
TAB . MVT OD
TAB . PARACETAMOL 650 mg TID
TAB. THYRONORM 100micrograms/PO/OD
TAB. RIBOFLAVIN 5mg/PO/BD
T. PANTOP 40mg/PO/OD
INJ.NEOMAL 1gm iv infusion
Syrup Mucaine gel 10ml/PO/TID
ZYT66 gel
Temp/BP/PR/SPO2 monitoring 4th hrly
On 06.1.2022
TAB . MVT OD
TAB . PARACETAMOL 650 mg TID
TAB. THYRONORM 100micrograms/PO/OD
TAB. RIBOFLAVIN 5mg/PO/BD
T. PANTOP 40mg/PO/OD
INJ.NEOMAL 1gm iv infusion
Syrup Mucaine gel 10ml/PO/TID
ZYT66 gel
On 07.1.2022
TAB . MVT OD
TAB . PARACETAMOL 650 mg TID
TAB. THYRONORM 100micrograms/PO/OD
TAB. RIBOFLAVIN 5mg/PO/BD
T. PANTOP 40mg/PO/OD
INJ.NEOMAL 1gm iv infusion
Syrup Mucaine gel 10ml/PO/TID
ZYT66 gel
On 08.1.2022
TAB . MVT OD
TAB . PARACETAMOL 650 mg TID
TAB. THYRONORM 100micrograms/PO/OD
TAB. RIBOFLAVIN 5mg/PO/BD
T. PANTOP 40mg/PO/OD
INJ.NEOMAL 1gm iv infusion
Syrup Mucaine gel 10ml/PO/TID
ZYT66 gel for L/A
Tab .Zincovit po/OD
Tab.ultracet po/QID
Tab fluconozole 150mg OD
On 09.1.2022
TAB . MVT OD
TAB . PARACETAMOL 650 mg TID
TAB. THYRONORM 100micrograms/PO/OD
TAB. RIBOFLAVIN 5mg/PO/BD
T. PANTOP 40mg/PO/OD
INJ.NEOMAL 1gm iv infusion
Syrup Mucaine gel 10ml/PO/TID
ZYT66 gel
Tab .Zincovit po/OD
Tab.ultracet po/QID
Tab fluconozole 150mg OD
Tab.WYSLONE 40mg po od
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