30 y/o F with b/l pedal edema, SOB and b/l knee joint pain

35y/o woman with b/l pedal edema, SOB and b/l knee joint pain 

Manvi Sharma 

Roll no 88 

2018 batch 

16th March 2022 

"THIS IS AN 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 CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT."

Chief complaints - 

A 35 y/o female who is a housewife presented to the OPD with chief complaints of 

high grade fever and cough with sputum since 5 to 6 days, 

b/l pedal edema (pitting type) since 5 days

and difficulty in breathing even at rest or after talking (grade 4)  since 5 days

History of presenting illness - 

The patient was apparently asymptomatic 1 yr back when she developed b/l knee joint pain and itching in upper aspect of chest and neck.The pain was insidious in onset and gradually progressive and also associated with morning stiffness. She was taking medication for this(?) 

At the same time she had itching over neck and chest due to which the area turned red and then black.

She also complained of generalized pain and muscle weakness of the proximal and distal(?) muscles since 1 yr 

There was complaint of b/l pedal edema and sob(grade 3) since 6 to 7 months which was gradually progressing to the present state. 

C/o vaginal discharge 8 to 9 months back which was curdy white amd later changes to watery. 

C/o oral and genital ulcers since 1 yr

C/o loss of taste since 8 months 

C/o throat pain since 8 months 

C/o weight loss over the last 1 yr (?) 

About 2 months back she came to the hospital with the above mentioned complaints and was diagnosed with DERMATOMYOSISTIS with vaginal candidiasis and given the following treatment - 

1.tab.wysolone 50mg po od

2.syp.mucaine 10ml/po/tid

3.tab.ultracet 1/2 po/QIT

4.candid cream for L/A 

Patient was referred to other health centre for muscle biopsy.

Her ANA immunofluoroscence showed homogeneous pattern.Intensity 4+ associated antigens involved-ds DNA,histones.

HRCT was done - 

IMPRESSION: Few patchy areas of ground glass opacities in peri bronchovascular distribution-s/o pneumonitis (Corads-4)

Her images from 2 months back - 

Treatment given - 

1.TAB.CALTEN

2.TAB.AUGMENTIN

3.TAB.NAPROXEN SODIUM

4.TAB.FOLVITE

5.CANDID CREAM

6.TAB.WYSOLONE

7.TAB.ESOMEPRAZOLE

8.TAB.SODIUM ALENDRONATE WEEKLY ONCE.

Previous X-RAYS - 

 

 

About 5 to 6 days back she developed high grade fever associated with chills and rigors which is continuous and relieves only on taking medication. She had cough from 5 to 6 days with sputum which is more during night time. She is experiencing shortness of breath even while talking and taking rest since 5 days. There is b/l pedal edema involving dorsum and upto below knee level, more on left side. 

When she went to the nearby facility they told her that it might be pneumonia and gave some medications but it did not help. 

Past history - 

No h/o HTN,DM, TB, asthma, thyroid problem, CAD 

Menstrual history -  

Age of menarche - 11 yrs 

Cycles - 3/25-28 , regular, no pain, no clots 

LMP - 9th march 

Marital history - 

Duration of marriage - 14 yrs

Non - consanguineous marriage 

Nulligravida (? Primary infertility) 

Recently adopted a girl from her sister in law 

Family history- not significant

Personal history - 

Appetite - lost since 5 to 6 days 

Diet - veg since 1 yr (adviced against meat due to joint pains) 

B&b movements - irregular from past 8 months 

Addictions - none 

She is a home maker who does her daily chores from morning to evening and takes rest in the afternoon. Currently , she is facing difficulty and complaints of generalized weakness and heaviness in body. 

General physical examination - 

The patient is conscious, coherent and cooperative and well oriented to time, place and person. 

Pallor - present 

No icterus , cyanosis , clubbing, lymphadenopathy 

B/l pitting type pedal edema seen 

Vitals - 

Temperature- Afebrile

BP- 150/100 mm Hg

PR- 114bpm

RR- 30cpm

SpO2- 93% @ RA

Systemic examination - 

CVS- S1, S2 sounds heard. No murmurs

RS- BAE+ NVBS heard

CNS- NAD

P/A- Soft, non tender, Bowel sounds heard

Investigations - 

USG ABDOMEN ON 15/3/22-

IMPRESSION: RIGHT RENAL CORTICAL CYST WITH WALL CALCIFICATION. 

2D ECHO ON 15/3/22- 

EF-60%

MILD TR WITH PAH

TRIVIAL AR/MR

GOOD LV SYSTOLIC FUNCTION 

NO DIASTOLIC DYSFUNCTION. 

CBP-

HB:9.9

TLC:9600

N/L/E/M:90/6/2/2

PCV:29.2

MCV:82

MCH:27.8

MCHC:33.9

RBC:3.56

PLT:1.77

LFT:

TB-0.82

DB-0.24

AST-16

ALT-18

ALP:147

ALB-2

A/G-0.62

RFT:

SR.UREA-29

SR.CREAT-0.9

NA+-137

K+-3.5

CL-:98

BGT:AB POSITIVE 

RBS:312 MG/DL

Chest x ray - 

ECG - 

PFT report on 16-3-22 

Provisional diagnosis - 

DERMATOMYOSISTIS TO R/O ILD 

Treatment - 

1.T.SEPTRAN DS TID 1--1--1

2.TAB.FLUCONAZOLE 150 MG OD 

1--X--X

3.OINT.CANDID MOUTH PAINT IN ORAL CAVITY

4.TAB.WYSOLONE 50 MG OD 1--X--X

5.TAB.FOLIC ACID 5 MG ONCE A WEEK.