PAIN ALONG LEFT UPPER LIMB 29 YEARS OLD FEMALE WITH C/O JOINT PAIN

 





29 years old female homemaker by occupation came to the General Medicine OPD with the 

Chief complaint:

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


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


        HOPI.: Patient was apparently asymptomatic 10 months ago. Then 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 


Associated with morning stiffness.


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 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. It was initially curdy white which later changed to watery discharge. Associated with itching. 


C/O weight loss of 4 kg over the last 10 months.


C/O oral ulcers and genital ulcers since 10 months.


-No h/o fever, cold, cough.


Past h/o: Not a k/c/o DM, HTN, BA, epilepsy, Asthma, CVA, CAD.


    No similar complaints in the past. 


Menstrual h/o: AOM- 11 years


                3/25-28, regular , no pains, no clots.


Marital h/o: ML- 14 years, NCM


     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


DVL REFERRAL WAS TAKEN-


INVESTIGATIONS



2D ECHO


ECG:

medication

Tab fluconazole po(stat)

Candid cream

Pantop(40mg-po/OD)

Ultraset(po1/2tabQID)

 Srp-Grilinctus 





Serology - Negative


RA Factor- Negative


CRP- Negative 







 


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