a 36year old female elog



 This is an online E logbook 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 a series of inputs from the available global online community of experts intending to solve those patients' clinical problems with collective current best evidence-based inputs.

The patient is a daily wage labourer who lives in a rural setup.

CHIEF COMPLAINTS ; 
Patient was admitted to the ICU on 27/9/22 at 12noon with bilateral  Pain in the upper and lower limb joints and tenderness of skin over surrounding tissue areaarea with early morning stiffness. 

HISTORY OF PRESENT ILLNESS;

  • Patient was apparently asymptomatic 5months ago then she developed pain of both the knee joints  and swelling followed by the ankle joints and nail bed.
Pain -
  • sudden in onset, gradually increasing in intensity, dragging type of pain, aggravates at night with numbness of both upper and lower limbs( when slept for a prolonged period of time in one position).
  • She went to a local RMP in nalgonda and was prescribed medication(analgesics) which relieved her symptoms temporarily.
The pain has affected her daily life activities ; she was not able to bend and wash her clothes and utensils, was unable to squat in the washroom.
                        
  •       3months ago she developed pain of both the shoulder joints with swelling, which involved her  elbow, wrist,  metacarpophalangeal and inter phalangeal joints. Her 20 year old daughter started helping her in performing normal activites.
       
  •        She stopped working 2months ago, because of her pain.
     
  •        1 month back, she developed pain on her left side of neck( over TMJ) so much that it restricted her mouth opening. She had pain while chewing food.No pain on swallowing. She was unable to walk one her own( needs support) . Takes about 15-20minutes for her  to stand up from bed.

Patient also had fever spikes at night since the past two days. Fever subsided without treatment.

PAST HISTORY;
a k/c/o hypothyroidism and TB.
  • In 1998, patient was diagnosed with TB for which she underwent a treatment course of 12months.Second attack of TB was in the year of 2018( with dry cough and SOB, and pain on left side below the nipple lateral to midclavicular line). 
  • Diagnosed with Hypothyroidism   10 years back( she noticed a swelling over the anterior part of her neck).Currently on medication (Thyronorm 25mcg).
Not a k/c/o DM,HTN, asthma. No allergies.
 
SURGICAL HISTORY ; Tubectomized 20 years ago.

DRUG HISTORY : Medication for pain (stopped the day before admission)and hypothyroidism.


FAMILY HISTORY : not significant.

PERSONAL HISTORY :
Mixed diet and decreased appetite.
Complaints of constipation since 2 weeks on alternate days.
No burning micturition.
Weight gain since 2 years.
Disturbed sleep due to her increasing pain.

ADDICTIONS ; None.

DAILY ROUTINE;
  1. She gets up at 5am and does her household chores like washing clothes, cleaning utensils and cooking food. 
  2. She would leave for work around 9 am (by walk) where she works in a farm(cotton and paddy) situated in the forest (3-5 km away).
  3. She has her lunch between 1-2pm (rice and dal).She usually reaches home at 7pm in the night, has dinner around 9-10pm and then go to sleep.



GENERAL EXAMINATION:
Pallor present
Icterus absent 
Cyanosis absent
Koilonychia  absent
Lymphadenopathy  absent
Edema  non pitting type present below the ankle.



Right knee joint

Left knee joint


Ankle edema
SYSTEMIC EXAMINATION;

RS ; BAE +. NVBS heard.

CVS ; S1 S2 heard. Apex beat localised.

CNS ; patient is conscious and coherent ; oriented to time place and person.

MOTOR Examination ;
 
Muscle mass  adequate. 

Tone normal.


IV-REFLEXES 
A. SUPERFICIAL REFLEXES 
  1.  Corneal reflex present
  2. Conjunctival reflex
  3.  Abdominal Reflex present
  4. Plantar reflex dorsiflexion. 
 B. DEEP TENDON REFLEXES
  1. Jaw jerk
  2. Triceps jer
  3. Finger flexion reflex present
  4. Knee jerk present
  5. Ankle jerk present
  6. Clonus
D. OTHERS 
  1. Hoffmans sign  present 
  2. Wartenbergs sign present 
  3. Rossalimos sign
Gait: She couldn't walk without support and was shivering while standing in a bent position. With hands and joints in a semiflexed position. 

LABORATORY INVESTIGATIONS ;












ECG 


X ray images. 


USG shoulder region. 




Provisional diagnosis:
Spondyloarthropathy???? RA?? POLYMYALGIA RHEUMATICA 



Treatment 


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