29 year Old Lady with Joint Pain and Itching skin

 

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

I shall be presenting and discussing this patient as a part of my Prefinal Examination General Medicine Assessment process.

 

 DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever. CONSENT obtained.

I thank Dr. Simran Ma'am (intern) for helping me understand more about this case

 Introduction : 

This case is about a 29 year old lady residing in a village in the southern part of India ,who takes care of her household and she came to us to seek help for

Chief Complaints :

        - B/L joint pains (knees) since 10 months

        - B/L itching in the upper aspect of chest and neck since 10 months 

DAILY ROUTINE OF THE PATIENT :

The patient lives in a family of 3 ..(of late the family has expanded) which constitutes her husband ,her mother in law and herself . They follow Islam.

A usual day in her life :

4.40 am : wakes up and bathes

5.00 am : Prayer 

 5.15 am : She doesn't sleep but lies on her bed and rests for another one or two hours since the work load is not enough in the household to begin her chores at 5 am itself

7.30 am : washes dishes from the last day, washes clothes,  makes the morning tea for herself and her family members

9.00am : gets food ready for her husband who goes out for work after breakfast 

9.30 am : Serves breakfast for her mother in law and herself

Rests for a while

11.00 am : Prepares for the day's cooking

Rests for a while

12.00 noon : cooks for the day

1.00 pm : Serves lunch for her husband who comes back during afternoon 

2.00 pm : Serves lunch for her mother in law and herself

3.00 pm : Rests 

4.00 pm : Prayer

5.00 pm : Makes tea for everyone in the house 

In the evening mostly all of them sit down and watch television 

7.00 pm : Preparations for dinner

8.30 pm : Serves dinner for the family and then for herself

10.00 pm : Sleeps

How the Disease affected and changed her daily life 

The disease manifested  almost around January last year when she began having joint pains, 

At the level of her daily life ,she expresses she began feeling tired and fatigued very easily

Where by after very short spans of work or chores she felt like lying down and taking some rest before the next work , 

Whenever she did a little bit of work , her joints seemed to become " tight " and painful .

The Lassitude was to an extent so much so that she yearned that there was someone who would get everything ready for her and get it for her at bed itself such that she wouldn't have to get up.

Please note : The words have been put just as expressed by the patient such that the intensity and nature of her problem is interpreted better .

       HISTORY OF PRESENTING ILLNESS :  Around 10 months ago she developed symmetrical b/l joint pains in the knees which was insidious in onset, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg (suggested by a local physician)

Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 

C/O Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.

C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.

C/O generalised pain.

C/O Difficulty in walking.

C/o weakness

C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, combing of hair.

C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

C/O Dyspnea on exertion (NYHA- 3), gradually

 progressive since 4-5 months.

C/O vaginal discharge since 7-8 months.

Past h/o: She has not experienced similar joint pains or itching in the past. 

Menstrual h/o:     

                Attained menarche at 12 years of age , 3/25-28, regular , no pains, no clots.

Marital h/o:     

                 Non consanginous marriage , married life of 14 years , Primary infertility (Nulligravida) 

Has recently adopted a girl from her sister-in-law. 

Family h/o:  No similar complaints in the family 

Personal h/o: 

            Diet- Mixed

           Appetite- Decreased

           Sleep- Inadequate since 10 months

           Bowel and bladder habits- Regular

           No addictions

           No known drug allergies 

General physical examination: The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished. 

Pallor- present

No icterus, cyanosis, clubbing, lymphadenopathy.

Pedal Edema- present 

O/E:

• Diffuse mottled erythematous hyperpigmentation (Heliotrope rash) noted on B/L cheeks, nose(bridge) involving nasolabial folds, ears, neck extending onto upper chest and back forming a ‘V’ on anterior chest (Shawl sign).

• Few hyper-pigmented macules noted on mid and lower back (‘V’ sign).

• Single erythematous macule noted over the right loin (Holsier sign).

• Pigmentation of B/L knuckles noted (Gottron’s Papules).

Vitals: 

Temperature- Afebrile

BP- 130/80 mm Hg

PR- 102 bpm

RR- 14 cpm

SpO2- 99% @ RA

SYSTEMIC EXAMINATION:

CVS- S1, S2 sounds heard. No murmurs

RS- BAE+ NVBS heard

CNS- NAD

P/A- Soft, non tender, Bowel sounds heard

Provisional diagnosis: 

DERMATOMYOSITIS WITH PRIMARY INFERTILITY 

GENITAL CANDIDIASIS

?SLE

DVL REFERRAL WAS TAKEN-

INVESTIGATIONS:

Serology - Negative

RA Factor- Negative

CRP- Negative 

TREATMENT : 

Note : On examination,  there is obliteration of cleft in the joint  due to synovial hypertrophy 

STUDIES

:    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5715209/

( about management options ( protocol of therapy and advantage of systemic drugs in cutaneous manifestations )

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5952016/

( Antimalarial drugs in Dermatomyositis )

https://advancesinrheumatology.biomedcentral.com/articles/10.1186/s42358-020-00134-8

( Efficacy of hydroxychloroquine )

https://academic.oup.com/rheumatology/article/41/1/7/1787912

(Treatment options)

https://www.sciencedirect.com/science/article/pii/S2589909019300188

( Bohan and Peter Criteria for  Dermatomyositis )

Courtesy : https://www.google.com/search?q=bohan+and+peter+criteria+for+dermatomyositis&client=ms-android-samsung-ga-rev1&prmd=invx&sxsrf=AOaemvK9J8_PAo3F6yAVsb79UTeZYooYqg:1642037145797&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjHvaGGya31AhW2RWwGHRu8DBEQ_AUoAXoECAIQAQ&biw=412&bih=756&dpr=2.63#imgrc=yR_VUdpp-7U8kM&imgdii=wysobDx0i_1dzM

Infertility and dermatomyositis

57 Year/ Female

 

I am Saranya ,a final year MBBS student.

Greetings to all my readers;

This is an elog documenting the patients that I witness during my Clinical Postings to enforce a greater patient centered learning .

 

 DEIDENTIFICATION : 

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

 

Introduction :  

Here we shall discuss about a lady who is a 57 year old homemaker hailing from India .

PRESENTING PICTURE OF THE PATIENT :

56 year old female who is a house wife by occupation , survived with one kid

Patient was apparently asymptomatic 21 years back, in 1990 she had one miscarriage and couldn’t conceive till 9 years. In 1999 she had her first child . 

No history of any medications for 9 years  . 

In 2003, had loose stools and vomitings and went to a near by hospital , didn’t subside on medication and she was taken to CMC vellore 

Her complaints subsided , where she was diagnosed with right ectopic kidney , hypothyroidism and hypertension was on thyronorm 50mcg  and tab.Telma  40mg. 

Regular follow up to CMC 2006, 2009, 2013 no complaints . 

In 2016, patient had recurrent loose stools for 2 months , and one episode of seizure  was taken to hospital , where on connecting monitor showed flat line CPR was initiated, she was revived after 7 cycles ,and she was having bradycardia  and was put on temporary pacemaker , and was also diagnosed with IBS

After follow up , she stopped her anti epileptic medications. 

She had similar GE symptoms in between subsided on medication. 

In august ‘2021 patient had history of low grade fever for 3 days followed by generalised weakness,  loss of appetite  and was admitted in hospital , where her bp was not recordable and was ionotropes and was diagnosed with pneumonia , septic shock , heart failure with reduced ejection fraction 35% ; patient was on mechanical ventilator for 2 days , indication : low sats as per the attender , cortisol levels where low on test , and MRI was done showing empty Sella ( pan hypopitutarism) and was started on wysolone 5mg . Hospital stay : 20 days , on ventilator for 2 days and ionotropes for 7 days , before her day of discharge , patient had recurrent hypoglycaemic episodes , was put on 25% dextrose .

She was discharged after 20 days.

On discharge Patient attenders observed she was drowsy and they thought due to her medications , she was drowsy for next 2 days , she was taken to the hospital and diagnosed with hyponatremia , was on medication for 2 days , attender observed she had irrelevant talk and self smile psychiatry referral was done diagnosed with schizophrenia . 

She was discharged after 4 days 

After 1 week patient complained of head ache and on checking her bp was 210/160mmhg 

Where she was admitted for 4 days and got discharged. 

TIMELINE OF EVENTS 

MRI

Panhypopituitarism

Courtesy declaration:  The following images are not original and have been taken for reference from the below mentioned source .

 Source : Davidson's Principles and Practice of Medicine

23^rd Edition

Update : 3rd December 2021

TREATMENT 

Follow up Update : 

12.June.2022

Test reports of May 2022

Present complaints in the patient : Fatigue

Spotters that I came across in my Clinical Postings

 

Greetings to all my readers

I am Saranya, a Final Year MBBS student .

Patient centered learning is the core basis of our education process wherein in the later days we can serve our patients better with the clinical knowledge that we gain during our training days .

 

This shall be an image based blog based on some of the beautiful findings I came across in my patients during my month long clinical postings .

 

Encounters with patients make us learn lengthy “chapters “ and  complicated “  syndromes “ swiftly and with ease and the lesson learnt is retained in our hippocampus for a lifetime unlike the blurry memory after hours of reading from the textbooks.

 

Here’s a few of such amazing experiences .

Several Icteric patients :

Icteric Sclera

Angle of Mouth Droop

Rheumatoid Hand

Alopecia , Receding hairline,

Possible Sheehans faces

Monteaux Test

Intradermal Purified Protein Derivative

Obesity and Abdominal Striae

Tenia dermatitis

Koilonychia/ Dysmorphic nails

Moon facies/ Cushingoid Facies

Hirsutism 

Hyperpigmented Knuckles in Megalobalstic Anemia

Pedal Edema with Club Foot

Taliesin Equino Varus

Unilateral Limb Swelling 

in Deep Vein Thrombosis

White out Lungs

Despite efforts , we lost this patient of ours  :( 

Clubbing

Gibbus: angular deformity of the spine 

?predisposing to the ulceration and excoriation

Ptosis and Madarosis

Subconjunctival Hemorrhage

Weils Disease

Purpura