A 45 yr old female withfacial rash,morning stiffness &joint pains

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I have been given this case to solve in an attempt to understand the topic of " Patient clinical data analysis" to develop my competancy in reading and comprehending clinical data including history, clinical finding, investigations and come up with a diagnosis and treatment plan.

Cheif Complaints:

A 45 year old female is tailor by occupation came with the cheif complaints of:

-facial rash since 4 days

-fever and body pains since 3 days

History of presenting illness:

Patient was apparently asymptomatic 10 years back then she developed joint pains which was associated with morning stiffness for 10mins, associated with limitation of movements 

The she was found to have Rf +ve and was on diclofenac and remained asymptomatic for 8 months

1 month back patient had an episode of loss of consciousness with cold peripheries with sweating.

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, swelling of the left leg with erythema, and local rise of temperature.

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 and certified as blind 2 years back .

No relevant drug 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- no

General examination:

Patient is conscious coherent cooperative and well-oriented with time, place, and person 

moderately built and nourished

Pallor  - Present 

No icterus, clubbing, cyanosis, lymphadenopathy, and edema 

Vitals:

Patient was afebrile

BP: 110/70 mmhg,

PR: 78bpm,

RR:18 cpm

SP02: 98%

Local examination:

Swelling at ankle associated with redness and local rise of temperature and dorsalis pedis pulses were felt.The erythematous rash was present on cheek bilaterally

Systemic examination:

CVS:

Inspection:

No rise in  JVP, 

no additional visible pulsations seen

no scars on chest

Palpation:

all inspectory findings are confirmed

apex beat normal at 5th ics medial to mcl

no additional palpable pulsations or murmurs

Percussion: normal heart borders seen 

Auscultation: S1 S2 heard no murmurs

Motor :

normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++

Sensory:

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

 

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: 

Hb- 6.9

TLC- 9700

Platelet count- 1.57lakhs/cumm

RBS- 130

Urea- 20

Creatinine- 1.1

Total bilirubin- 0.45

Direct bilirubin- 0.17

AST- 60

ALT- 17

Albumin- 2.18

Sodium- 136

Potassium- 3.3

Chloride- 98

Provisional Diagnosis: 

Secondary sjogren syndrome

Anaemia with Left lower limb cellulitis