Pre-final Case: 31 year old female with fever and joint pains

Neha Pradeep

9th Semester

Roll no. 99 

This is online E log book 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 series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome .

I’ve been given this case to solve in an attempt to understand the topic of “patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with diagnosis and treatment plan.

CASE: 

A 31 year old female, came with the chief complaints of: 

        1) Oral ulcers since 6 months

        2) Fever on and off since 2 weeks

        3) Bilateral knee pain since 2 weeks

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 years ago (March 2020)

                                   

She then developed pain in her right shoulder because of which she could not raise her hand above her shoulders. It was dull aching type and continuous, for which she went to an Orthopaedic and was given medication. The pain kept alternating between right and left shoulder and sometimes both simultaneously. She then experienced tightness of shoulder joints on waking up and needed someone to pull her up from the bed. Her pain was relieved on medication though it kept recurring for 6 months. 

One month later she noticed swelling in the proximal interphalangeal joints. It was associated with decreased function. She was not able to write properly, open bottle cap or close a tap.

She also developed bilateral knee pains and generalized weakness.

Then she developed fever, oral ulcers , redness of eyes, diminished vision, and facial puffiness. She then went to a private hospital. 

She developed hair loss 2 years ago, which was gradually progressive.

On routine investigations,  nephrotic range proteinuria was detected in her urine sample, increased protein creatinine ratio of 4.99 due to which they decided to a kidney biopsy.

BIOPSY FINDINGS: focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS

ANA PROFILE: Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN were present.

Based on this the diagnosis of SLE was made.

She was prescribed Tab. OMNOCORTIL 5mg for 3 days, which was tapered over 6 months to 2.5mg.

After 6 months, steroids were stopped and was started on

        - Tab. MMF for 4 months (2 tab at 8 AM and 1 tab at 8 PM), 

             => Which she used and stopped after one month after tapering. 

            => She was also advised to perform exercises.

In January 2022,

     - She was started on FOLITRAX after which she noticed increase in number of oral ulcers, so she  went to a private hospital 15 days later, and was started again started on OMNOCORTIL 5mg.

At present, the patient is complaining of bilateral knee pains since two weeks, aggrevated since last 3 days, associated with difficulty in walking and getting up when sitting. Pain is worse in the morning. 

Fever since two weeks, low grade initally and progressive. Not associated with chills and rigors. Relieved on medication. Not associated with vomiting, diarrhoea, cough and cold. 

Oral ulcers since 6 months, aggregated since last three months because of which the patient is unable to eat comfortably. There has been weight loss of 6 kgs in the last 3 months. No bleeding or discharge from the ulcer. 

Pain in the left hypogastrium and epigastrium after eating. Two episodes of vomiting last night, watery consistency, no good particles. 

PAST HISTORY:

Patient is a known case of HYPOTHYROIDISM since 4 years and is on Thyronorm 50mcg .

Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA. 

PERSONAL HISTORY:

Appetite- normal

Diet -mixed

Sleep - disturbed, due to pain

Bowel and bladder -  regular

No addictions, no known allergies for food or drugs.

MENSTRUAL HISTORY: 

She bleeds for 3 days in a 30 day cycle 

She uses 3 pads per day.

Recently, she complains of spotting 5 days before her first day of menses. 

MARITAL HISTORY: 

She got married at age of 24years.

ANTENATAL HISTORY: 

P3 L2 A1

In 2015, her first pregnancy reached full term and NVD was done. 

She developed high grade fever in her 6th month, and was diagnosed with malaria.

She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication. 

In 2019, her third pregnancy, reached full term and NVD was done. 

FAMILY HISTORY:

No similar complaints in the family.

No significant family history.

SURGICAL HISTORY:

Cataract surgery in left eye in Jan 2022

TREATMENT HISTORY:

Patient is currently on:

1. Tab. MMF 500mg PO BD (8AM & 8 PM)
2. Tab. FOLITRAX 10mg weekly once 
3. Tab. LIVOGEN PO BD 
4. TAB. HCQ 200mg OD
5. Tab. SHELCAL PO OD
6. Tab. THYRONORM 50mcg

GENERAL EXAMINATION:

With consent taken from the patient and her husband in a written form, the patient was examined in a well lit room in supine as well as sitting position. 

Patient is conscious, coherent and cooperative. 

No signs of pallor, icterus, kolionychia, cyanosis, generalized lymphadenopathy, and edema. 

VITALS: 

Temperature: 102 degrees F

Blood Pressure: 110/70

Pulse Rate: 99 bpm

Respiratory Rate: 18 cpm

Fever Chart: 

Upto 31/03/22

SYSTEMIC EXAMINATION: 

Cardiovascular System:

I) INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

II) PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

III) PERCUSSION:

Right and left heart borders percussed.

IV) AUSCULTATION:

S1 and S2 heard, no added thrills and murmurs heard.

Per Abdomen Examination:

I) INSPECTION:

Shape – scaphoid

Flanks – free

Umbilicus – inverted

All quadrants of abdomen are moving equally with respiration.

No dilated veins, hernial orifices, sinuses

No visible pulsations.

II) PALPATION:

No local rise of temperature and tenderness

All inspectory findings are confirmed.

No guarding, rigidity

Deep palpation- no organomegaly.

III) PERCUSSION:

There is no fluid thrill, shifting dullness.

Percussion over abdomen - tympanic notes heard

IV) AUSCULTATION:

 Bowel sounds are feeble.

Respiratory System:

I) INSPECTION:

Chest is bilaterally symmetrical

Trachea – midline in position.

Apical Impulse is not appreciated 

 Chest is moving normally with respiration.

No dilated veins, scars, sinuses.

II) PALPATION:

Trachea – midline in position.

Apical impulse is felt on the left 5th intercoastal space.

Chest is moving equally on respiration on both sides

Tactile Vocal fremitus - appreciated 

III) PERCUSSION:

The following areas were percussed on either sides- 

Supraclavicular

Infraclavicular

Mammary

Axillary

Infraaxillary

Suprascapular

Infrascapular

Upper/mid/lower interscapular were all RESONANT.

IV) AUSCULTATION:

Normal vesicular breath sounds heard 

No adventitious sounds heard.

Central Nervous System Examination: 

HIGHER MENTAL FUNCTIONS:

Patient is conscious, well oriented to time, place and person.

All cranial nerves - intact

Motor system

                              Right.                  Left

BULK 

Upper limbs.            N                         N

Lower limbs             N                         N

TONE

 Upper limbs.          N                        N

 Lower limbs.          N                        N

POWER

 Upper limbs.          5/5                    5/5

 Lower limbs           5/5                    5/5

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated. 

ECG: 

USG Report: 

Impression: Small Gall Bladder Polyp is seen

Chest X-ray: 

Clinical Photos: 

Laboratory Investigations:

HEMOGRAM:

Hemoglobin: 9.3

TLC: 3500

N/L/E/M: 78/15/2/5

Platelet: 2.3

MCV: 77 

MCH: 25.8

MCHC: 33.5 

RDW: 15.5 

CUE:

Albumin: Trace

Sugars: Nil

Pus Cells: 2-3

Epithelial cells: 2-3

APTT: 32 seconds

PT: 16 seconds

INR: 1.11

CRP: 0.6

ESR: 55

RA Factor: Negative

LFT:

TB: 0.9

DB: 0.2

SGOT: 18

ALT: 16

ALP: 12.3

TP: 6.3

Alb: 3.16

A/G ratio: 1.01

RFT:

Urea: 24

Creatinine: 0.7

Na: 138

K: 4.1

Cl: 105

PROVISIONAL DIAGNOSIS:

SYSTEMIC LUPUS ERYTHEMATOSIS - CLASS III LUPUS NEPHRITIS

WITH HYPOTHYROIDISM 

WITH BILATERAL RETINAL VASCULITIS .

WITH RHEUMATOID ARTHRITIS (?)

TREATMENT:

1. IVF NS RL @ 75ml/hr
2. Inj. NEOMOL 1 gm IV SOS
3. Tab. DOLO 650mg PO/QID
4. MUCOPAIN GEL for L/A over ulcers.
5. Tab. MMF 500mg PO BD (8AM & 8 PM)
6. Tab. FOLITRAX 10mg weekly once 
7. Tab. LIVOGEN PO BD 
8. TAB. HCQ 200mg OD
9. Tab. SHELCAL PO OD
10. Tab. THYRONORM 50mcg

Ophthalmology Referral: 

DVL Referral:

Reference Links:

Intern E-log: https://caseopinionsbyrollno156.blogspot.com/2022/03/30-year-old-with-bl-knee-pains-and-fever.html

Sudhamshi Reddy (80): https://sudhamshireddy.blogspot.com/2022/03/a-31-year-old-women-with-high-grade.html

Sofia Jabeen (86): https://sofiajabeen1912.blogspot.com/2022/03/year-old-female-with-fever-and-knee.html