36 year old female with joint pains,oral ulcers

 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.

E.Laharika 

Roll no: 29

• 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 a diagnosis and treatment plan.  

CASE PRESENTATION 

      A  36 year old female,tailor by occupation, presented with chief complaints of:

• Multi joints pain since 2 months 
• morning stifness of joints since 1 month 
• Menorrhagia since 1 month
• Oral ulcers since 20 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back, then she had rapid weight gain, menorrhagia, multiple joint pains, she visited a hospital and was found that her TSH was >100 mlU/L and was started on THYRONOME 100 micrograms.

Her menorrhagia subsided, but she continues to have multiple joint pain (all small joints and large joints) associated with swelling of joints, morning stiffness for 30mins, on evaluation she was found to have CRP (+), Hb-10.8gm/dl, Uric acid-7.8 and was started on T. ALLOPURINOL100mg BD.

Her joint pains are associated with on and off low grade fever since 2months, using T.PCM 650mg BD since 2months. 

On Dec 29th:

 ANA- 3.18(if >1.2 strongly positive)

Anti CCP -1.4 UI/ml (Negative)

Rh factor- Negative 

TSH -16.9 (continued on T. THYRONOME 100 micrograms)

Since 5 days Patient tells that her joint pains and swellings subsided 

C/O oral ulcers since 20 days

C/O Blackish spots over malar aspect of face since 15days

MRI spine done 3/1/22 - Multiple level disc protussion causing thecal sac indentation and B/L C5-C6 mild neural foraminal stenosis

PAST HISTORY 

K/C/O Hypothyroidism (on T.THYRONORM 100 micrograms)

N/K/C/O DM, HTN, CAD

No previous hospitalisation

GENERAL EXAMINATION 

Pt is conscious,coherent and cooperative 

Pallor (+)

No Icterus/cyanosis/koilonychia/generalised lymphadenopathy/pedal edema

VITALS:

 

Temp-99.6 F

Pr-115bpm

BP-110/80 mmhg

Rr-21/min

Spo2-98% @RA

GRBS-132 mg/dl

SYSTEMIC EXAMINATION 

Ulcer over left lateral aspect of tongue

Goitre(+)

Cvs-s1 s2 +,no murmurs

R/S- bae+,nvbs

Cns-no fnd

P/A-soft,nt

INVESTIGATIONS 

PROVISIONAL DIAGNOSIS

 

Sero negative arthritis (2° to RA ?SLE) with k/c/o hypothyroidism .

TREATMENT 

T.THYRONORM 100mcg po od bbf

Syp.MUCAINE GEL 10ml po tid

T.RIBOFLAVIN 5mg po bd

T.ZINCOVIT po od

T.PCM 650mg po sos

T.PAN 40mg po od

ZYNTEE gel for l/a

Inj.NEOMOL 1g iv sos (if temp >100°F)

Tab.ULTRACET 1/2 tab qid

Tab.WYSLONE 40mg po od

Temp/BP/PR/SPO2 monitoring 4th hrly.

Sensitivity and specificity of anti ccp and rf in Rheumatoid arthritis:

The sensitivity and specificity of anti-CCP reactivity for the diagnosis of rheumatoid arthritis (RA) were 74.0% and 94.5%, respectively; the corresponding results for RF were 69.7% sensitivity and 81.0% specificity.