Short case :fever with joint pains

 A 45-year-old female tailor by occupation came to the hospital on 2/6/22 with

C/O fever on and off, associated with generalized body pains, loss of appetite for 3 months 

C/O  facial rash since 4-5 days 

HISTORY OF PRESENT ILLNESS: Patient was apparently asymptomatic

10 years back then she developed joint pains, the fleeting type associated with morning stiffness for 10 min , not associated with swelling for 2 months for which she was treated at a private hospital and found to have?RA factor positive 

patient was asymptomatic until 8 months back then she developed joint pains? post covid vaccination was treated at a private hospital with medications.

1 month back patient was having an episode of loss of consciousness with cold peripheries with sweating [grbs 7mg/dl] after taking Tab Glimi M2 prescribed by a local practitioner for high sugars?250mg/dl

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, associated swelling of the left leg with erythema, and local rise of temperature[?cellulitis]

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 was 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- nil

GENERAL EXAMINATION :

A 45-year-old female who is conscious coherent cooperative and well-oriented with time, place, and person 

moderately built and nourished

Pallor  +

no icterus, clubbing, cyanosis, lymphadenopathy, and edema 

 

Local examination :

There is swelling in the left lower Limb on the lateral aspectWith itching, local rise pf of temperature and redness.Pigmentation is seen and swelling was associated with pain which is throbbing in nature non radiating type no aggrevating or releiving factors.

Dorsalis pedis artery is felt. 

Erythematous rash is present on the cheek bilaterally.It is not associated with itching now. 10dsys back there was itching which was gradually subsided. 

SYSTEMIC EXAMINATION;

CVS:

inspection shows no scars on the chest, no features of 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 or additional sounds

CNS: C/C/C

MOTOR-: normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++

SENSORY :

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

sensations could not be assessed at lt ll [dressing]

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 

INVESTIGATIONS:

Haematology : hemoglobin 6g/dl 

X-rays :

Treatment:

1.INJ PIPTAZ 4.5 gm IV/ TID.

2.INJ METROGEL100 ML IV/TID

3.INJ NEOMOL1GM/IV/SOS

4.TAB CHYMORAL FORATE PO/TID

5.TAB PAN 40 MG PO/ OD.

6.TAB TECZINE10 MG PO/OD

7.TAB OROFERPO/OD.

8.TAB HIFENAC-P PO/OD

9HYDROCOTISONE cream 1%on face for 1week.

Provisional diagnosis :

SECONDARY SJOGRENS SYNDROME 

LEFT LOWER LIMB CELLULITIS WITH BILATERAL OPTIC ATROPHY