45 Y/O female with rash

 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.

2 months back- c/o dryness and burning sensation of eyes

Difficulty in eating solid food, decreased salivation seen

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 

VITALS:

Patient was afebrile at the time of presentation

BP: 110/70 MMHG, B/L

PR: 72BPM, regular and normal volume,felt bilaterally

RR:18 CPM

SP02:98 with RA

LOCAL EXAMINATION:

left lower limb swelling was present  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?malar rash 

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 

PROVISIONAL DIAGNOSIS: 

? Secondary sjogren syndrome

Anaemia secondary to chronic inflammatory disease

with LT LL cellulitis 

B/L Optic atrophy

REFERRALS DONE:

DERMATOLOGY

OPHTHALMOLOGY

SURGERY

INVESTIGATIONS

ANA REPORT