25 F with joint pains, facial puffiness, fever , weakness

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CONSENT AND DEIDENTIFICATION :

 

The patient and the attenders have been adequately informed about this documentation and privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whomsoever.

CHIEF COMPLAINTS

•25 YEAR OLD FEMALE, HOUSE WIFE BY OCCUPATION, RESIDENT OF NALGONDA CAME WITH THE CHIEF COMPLAINTS OF

•MULTIPLE JOINT PAINS SINCE 3 YEARS

•FACIAL PUFFINESS SINCE 2 WEEKS

•FEVER SINCE 5DAYS

•GENERALISED WEAKNESS SINCE 5DAYS

•AND HEADACHE SINCE 5DAYS

•SHORTNESS OF BREATH SINCE 3DAYS

HISTORY OF PRESENT ILLNESS

•PATIENT WAS APPARENTLY ASYMPTOMATIC 3 YEARS AGO THEN SHE DEVELOPED MULTIPLE JOINT PAINS INVOLVING LARGE AND SMALL JOINTS, WITH NO SWELLING OF JOINTS, INTERMITTENT IN NATURE,THEY USED TO DISTURB HER ROUTINE HOUSEHOLD ACTIVITES AND HAD NO MORNING STIFFNESS

•SHE DEVELOPED FEVER SINCE 15DAYS, HIGH GRADE FEVER ASSOCIATED WITH CHILLS AND RIGORS, INTERMITTENT IN NATURE, NO DIURNAL VARIATION RELIEVED ON TAKING MEDICATION

•NOT ASSOCIATED WITH COUGH

•ASSOCIATED WITH HEADACHE AND  GENERALISED BODYPAINS – HEADACHE - FRONTAL REGION, INTERMITTANT IN NATURE , RELIEVED ON MEDICATIONS 

•PATIENT WAS COMPLAINING OF SHORTNESS OF BREATH SINCE 3DAYS ON ORDINARY ACTIVITY, MAINLY DURING THE FEVER EPISODE, RELIEVED ON REST, NO DIURNAL VARIATION. 

•NO ORTHOPNEA, PAROXYSMAL NOCTURNAL DYSPNEA, PROFUSE SWEATING, CHESTPAIN ,PALPITAIONS, WHEEZE.

 

PAST HISTORY

•K/C/O HYPOTHYROIDISM SINCE 5 YEARS  ON TAB.LEVOTHYROXINE 25MCG/PO/OD

•H/O USAGE OF STERIODS FOR MULTIPLE JOINT PAINS SINCE 3YEARS

•H/O 3 ABORTIONS PREVIOUSLY – 2 IN FIRST TRIMESTER 

• 1 IN 2ND TRIMESTER

 

•TWO COMPLETE SPONTANEOUS ABORTIONS IN FIRST TRIMESTER

•MEDICAL TERMINATION OF PREGANCY IN 2ND TRIMESTER AS FETAL HEART BEAT WAS ABSENT

•NOT A KNOWN CASE OF HYPERTENSION, DIABETES MELLITUS, CORONARY ARTERY DISEASE, CEREBRO VASCULAR ACCIDENTS, TUBERCULOSIS,ASTHMA OR SEIZURE DISORDER 

 

•FAMILY HISTORY – NO SIGNIFICANT FAMILY HISTORY

 

PERSONAL HISTORY

•MIXED DIET

•SOUND SLEEP

•AQEDUATE APPETITE

•BOWEL AND BLADDER HABITS – REGULAR 

•NO ADDICTIONS

GENERAL PHYSICAL EXAMINATION

 

•Patient is conscious, coherent and cooperative

     Well oriented to time, place and person.

•Moderately built and Moderately nourished.

•Pallor and Anasarca present

•icterus, cyanosis, clubbing, lymphadenopathy 

•JVP not raised

 

 

 

VITALS AT PRESENTATION:

 

•Blood Pressure: 130/70 mmHg, right arm in supine position

•Pulse Rate: 92 beats per min, regular, normal volume.

•Respiratory Rate : 20 cycles per min.

•Temperature: 100F

•SpO2 : 98% on Room Air  

•GRBS: 132 mg/ dl

 

 

SYSTEMIC EXAMINATION

 

 •RESPIRATORY SYSTEM:

 INSPECTION

•Chest Is elliptical, bilaterally symmetrical

•Trachea is central in position

•Chest movements are symmetrical on both sides

•No scars.

•No visible pulsations


•Apical impulse not seen

PALPATION:


All inspectory  findings are confirmed


No local rise of temperature


No Tenderness


Trachea is central ,chest movements are symmetrical on both sides


Tactile Vocal Fremitus: Normal in all areas

 

   

PERCUSSION:

   •Resonant note heard in all areas.

  AUSCULTATION:

  •Bilateral air entry present

  •Normal Vesicular Breath sounds heard

  • No added sounds

 

 

SYSTEMIC EXAMINATION

 

CARDIOVASCULAR SYSTEM:

 

INSPECTION

•Elliptical and Bilaterally symmetrical chest

• Apical impulse not seen.

• Trachea appears to be central in position

•No visible pulsations/engorged veins/scars/sinuses on chest wall.

PALPATION

•Apex beat palpable at  left 5th Intercostal space at midclavicular line.

•No palpable heaves, thrills present

 

•AUSCULTATION

 

•S1 and S2 normally heard.

•No murmurs heard.

 

 

SYSTEMIC EXAMINATION

 

•PER ABDOMEN :

 

•Scaphoid shaped

•No visible pulsations/engorged veins/scars/sinuses.

•Soft, Non tender.

•No guarding and rigidity.

•No organomegaly

•Bowel sounds present.

SYSTEMIC EXAMINATION

 

•CENTRAL NERVOUS SYSTEM:

   Patient is Right handed

•Higher mental functions :Patient is oriented to time,place and person.

•Bilateral Pupils: Normal in Size and reacting to light.

•Cranial Nerves: Normal.

•Signs of Meningial 

Sensory system - Normal

•Motor System : Power 5/5 in all 4 limbs.

• Tone – Normal in all 4 limbs

•Reflexes – Biceps Triceps Supinator Knee Ankle in both limbs 

•                      ++         ++             +             ++    +

•Plantors - Flexion in both limbs

 

JOINT EXAMINATION

•GENERAL APPEARANCE – NO SWELLING OR DEFORMITY

•INSPECTION – NO REDNESS,SCARS OR RASH

•ON PALPATION – NO EFFUSION , NO WARMTH ,TENDERNESS OR CREPITUS WERE PRESENT

•NO RESTRICTION OF MOVEMENT  

PROVISIONAL DIAGNOSIS

MENINGITIS

•?ARTHROPATHY

• CUSHINGS SYNDROME

•ANEMIA

•HYPOTHYROIDISM

ECG

CHEST XRAY

USG

COURSE IN THE HOSPITAL

•25YEAR OLD FEMALE, HOUSEWIFE, RESIDENT OF NALGONDA PRESENTED WITH THE ABOVE MENTIONED COMPLAINTS TO  THE CASUALTY

•H/O FEVER SINCE 5DAYS ASSOCIATED NECK STIFFNESS AND WAS SUSCPECTED TO HAVE MENINGITIS AND BLOOD AND URINE CULTURES WERE SENT

•ATTENDANTS DENIED FOR LUMBAR PUNCTURE

•IV ANTIBIOTICS WERE STARTED –  INJ.MONOCEF 1GM IV BD

•AS CONTINIOUS FEVER SPIKES WERE PRESENT AND WITH RAISED TOTAL LEUCOCYTE COUNTS ANTIBIOTICS WERE ESCALATED TO

•INJ.PIPERACILLIN + TAZOBACTUM 4.5GM IV TID

 

•WITH USAGE OF STEROIDS FOR 3 YEARS

   PATIENT WAS SUSPECTED TO HAVE STEROID

   INDUCED CUSHING SYNDROME

  TAB.PREDNISOLONE 5MG PO/OD 

ANA PROFILE

ORTHOPEDIC OPINION  WAS TAKEN FOR NECK PAIN AND ADVISED NO ACTIVE INTERVENTION FROM THEIR SIDE

•NEUROLOGIST OPINION WAS TAKEN AS PATIENT COMPLAINED OF NECK PAIN WITH STIFFNESS SINCE 3DAYS WITH B/L EYE ABDUCTION RESTRICTION AND  WAS SUSPECTED TO HAVE RAISED INTRACRANIAL TENSION ?ASPETIC MENINGITIS ?BENIGN INTRACRANIAL HYPERTENSION

•MRI BRAIN, FUNDOSCOPY AND LUMBAR PUNCTURE WAS ADVICED

Xray Neck

MRI BRAIN

 

•AT THE TIME OF DISCHARGE FEVER SPIKES WERE ABSENT AND NECK PAIN WAS REDUCED, PATIENT WAS DISCHARGED IN HEMODYNAMICALLY STABLE CONDITION AND WAS ASKED TO REVIEW TO REVIEW TO GENERAL MEDICINE OPD AFTER 1 WEEK

 

DIAGNOSIS

•?SJOGRENS SYNDROME

•?SYSTEMIC LUPUS ERYTHEMATOSUS

•VASCULITIS WITH ACUTE INFARCT IN PONS

•CUSHINGS SYNDROME

•STEROID INDUCED NEPHROPATHY

•ANEMIA OF CHRONIC DISEASE (NORMOCYTIC-NORMOCHROMIC)

•HYPOTHYROIDISM

ADVICE AT DISCHARGE

•TAB. PREDNSIOLONE 5MG PO/OD  ON FOR 5DAYS

•TAB.HYDROXYCHLOROQUINE 200MG  PO/OD TO CONTINUE

•TAB. LEVOTHYROXINE 25MG PO/OD CONTINUE

•TAB.ECOSPRIN 75MG PO/OD  TO CONTINUE

•TAB.DOLO 650MG/PO/SOS