Final practical examination: Short case

Anigani Kavya

Hall ticket no: 1701006009

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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 competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.

45 year old female fever with rash

A 45 year old female tailor by occupation came with the cheif complaints of:

-facial rash since 4days

-fever and body pains since 3days

History of presenting illness:

Patient was apparently asymptomatic 10 years back then she developed joint pains which was associated with morning stiffness for 10mins, she was found to have Rhematoid factor positive

1 month back patient had an episode of loss of consciousness with cold peripheries with sweating.

10 days back patient developed fever and abdominal pain for which she was treated at a private hospital later she developed an erythematous rash over the face with itching, swelling of the left leg with erythema, and local rise of temperature.

Past History:

Patient had a history of diminution of vision at age of 15 years started using spectacles but there was gradual, progressive, painless loss of vision and certified as blind 2 years back .

No relevant drug, trauma history present

No similar complaints in family

Not a known case of  DM/HTN/ASTHMA/CAD /EPILEPSY/TB

Personal history:

Diet- mixed

Appetite- decreased

Bowel and bladder- regular

Sleep- disturbed

Addictions- no

General examination:

Patient is conscious coherent cooperative and well-oriented with time, place, and person 

moderately built and nourished

Pallor  - Present 

No icterus, clubbing, cyanosis, lymphadenopathy, and edema 

Vitals:

Patient was afebrile

BP: 110/70 mmhg,

PR: 78bpm,

RR:18 cpm

SP02: 98%

Local examination:

Swelling at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt.The erythematous rash was present on the face sparing the nasolabial fold.

Systemic examination:

CVS:

Inspection shows no scars on the chest, no raised JVP, no additional visible pulsations seen

all inspectory findings are confirmed

apex beat normal at 5th ics medial to mcl

no additional palpable pulsations or murmurs

percussion showed normal heart borders

auscultation S1 S2 heard no murmurs

MOTOR-: normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++

SENSORY :

touch, pressure, vibration, and proprioception are normal in all limbs

GIT:

inspection- normal scaphoid abdomen with no pulsations and scars

palpation - inspectory findings are confirmed

no organomegaly, non tender and soft 

percussion- normal resonant note present, liver border normal

auscultation-normal abdominal sounds heard, no bruit present

RESPIRATORY:

inspection: normal chest shape bilaterally symmetrical, mediastinum central

no scars, Rr normal, no pulsations

palpation: Insp findings are confirmed 

percussion: normal resonant note present bilaterally 

Investigatinons:

Hb- 6.9

TLC- 9700

Platelet count- 1.57lakhs/cumm

RBS- 130

Urea- 20

Creatinine- 1.1

Total bilirubin- 0.45

Direct bilirubin- 0.17

AST- 60

ALT- 17

Albumin- 2.18

Sodium- 136

Potassium- 3.3

Chloride- 98

Diagnosis:

Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease with Left lower limb cellulitis