A 35yr old female with cough and dyspnea

This is an online E log book to discuss our patient's de-identified health data shared after taking 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 patient's clinical problems with collective current best evidence based inputs.

RITHIKA KUNAPAREDDY

IDENTIFICATION :

The privacy of the patient is being entirely conserved. No identifiers shall be revealed through out the piece of work whatsoever.

CONSENT : An informed consent has been taken from the patient in the presence of the family attenders and other witnesses as well and the document has been conserved securely for future references.

ACKNOLEDGEMENTS:

https://61tejarshini.blogspot.com/2022/01/medicine-case-discussion.html

https://rhea9895.blogspot.com/2022/01/29-years-old-female-with-co-joint-pains.html

https://nikitha0510.blogspot.com/2022/03/dermatomyositis.html

I am extremely grateful toDr. Saicharan Kulkarni sir (PG) for guiding me through the case and helping me build this blog

March 15,2022

CASE:

35 years old female homemaker by occupation came to the General Medicine OPD with the CHIEF COMPLAINTS of dyspnea in rest since 4 days

cough since 4 days

B/L joint pains associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days

High grade fever since 1 day

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 12 months ago.

Then she developed symmetrical bilateral joint pains in the knees which was insidious in on set, gradually progressive, no aggravating factors and relieved on medication i.e. Tab. HYDROXYCHLOROQUINE 200 mg

Associated with morning stiffness.

Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black.

C/O Alopecia since 12 months. It was gradually progressive leading to severe hair loss over the past 12 months. Associated with thinning of hair.

C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands since 12 months

C/O generalized pain.
C/O Difficulty in walking.
C/O distal muscle weakness manifested in the form of difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt,

C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

C/O vaginal discharge since 10 months. It was initially curdy white which later changed to watery discharge. Associated with itching.

C/O weight loss of 4 kg over the last 10 months.
C/O oral ulcers and genital ulcers since 10 months.

C/O Dyspnea on exertion (NYHA- 3), gradually progressive since 6 months.

She visited many local RMPs, received pain killers as there is no improvement, she visited a health center 2 months back

Presence of facial hair since 1 month

C/O Dyspnea on rest (NYHA- 4), gradually progressive since 4 days

h/o cough since 4 days associated with sputum.

-h/o fever since 4 days

C/o throat pain since 4 days

Past History:

Not a K/O/C of HTN, BA, epilepsy, Asthma, CVA, CAD.

Had similar complaints in the past 2 months.

Diagnosed with diabetes after coming to the hospital on 15th March

Menstrual History

AOM- 11 years

3/25-28, regular , no pains, no clots.

Marital History

ML- 14 years, NCM

Primary infertility (Nulligravida)

Has recently adopted a girl from her sister-in-law.

Family History

No similar complaints in the family .

DAILY ROUTINE OF THE PATIENT :

The patient lives in a family of 3 which constitutes her husband ,her mother in law and herself . They follow Islam.

A usual day in her life :

4.40 am : wakes up and bathes

5.00 am : Prayer

5.15 am : She doesn't sleep but lies on her bed and rests for another one or two hours .

7.30 am : washes dishes from the last day, washes clothes, makes the morning tea for herself and her family members

9.00am : gets food ready for her husband who goes out for work after breakfast

9.30 am : Serves breakfast for her mother in law and herself

Rests for a while

11.00 am : Prepares for the day's cooking

Rests for a while

12.00 noon : cooks for the day

1.00 pm : Serves lunch for her husband who comes back during afternoon

2.00 pm : Serves lunch for her mother in law and herself

3.00 pm : Rests

4.00 pm : Prayer

5.00 pm : Makes tea for everyone in the house

In the evening mostly all of them sit down and watch television

7.00 pm : Preparations for dinner.

8.30 pm : Serves dinner for the family and then for herself

10.00 pm : Sleeps

Personal History

Diet- Mixed

Appetite- Decreased

Sleep- Inadequate since 12 months. Wakes at 2 AM-3AM because of pain in legs.

Bowel and bladder habits- Irregular

C/O loose stools for 4 days followed by constipation for 3 days since 8 months.

No addictions

No known drug allergies .

Following are the clinical images when she visited health center 2 months back:

Single erythematous macule noted over the right loin (Holster sign).

Diffuse mottled erythematous hyperpigmentation (Heliotrope rash) noted on B/L cheeks, nose(bridge) involving nasolabial folds, ears, neck extending onto upper chest and back forming a ‘V’ on anterior chest (Shawl sign) and (V sign).

Mottled erythematous lesions on the palms.

Pigmentation of B/L extensor surfaces of PIP, DIP joints noted (Gottron's papules).

She was diagnosed with dermatomyositis with vaginal candidiasis

Treatment given 2 months back:

Tab.wysolone 50mg po/od

Syp.mucaine 10ml/po/tid

Tab.ultracet 1/2 po/QIT

Candid cream for L/A is advised.

Patient was referred to other health center for muscle biopsy.

Patient went to health center, her ANTI NUCLEAR ANTIBODY IMMUNOFLUOTESCENCE showed homogeneous pattern. Intensity 4+ associated antigens involved-ds DNA, histones.

HRCT WAS DONE ON 21/1/22

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

She didn't undergo muscle biopsy as the doctors there advised it is not necessary

THEY PRESCRIBED:

TAB.CALTEN

TAB.AUGMENTIN

TAB.NAPROXEN SODIUM

TAB.FOLVITE

CANDID CREAM

TAB.WYSOLONE

TAB.ESOMEPRAZOLE

TAB.SODIUM ALENDRONATE WEEKLY ONCE.

She is moderately built and moderately nourished
Pallor- present
No icterus, cyanosis, clubbing, lymphadenopathy
Pedal Edema- present

O/E:

Patient images after treatment of 2 months

DEVELOPED FACIAL HAIR GROWTH POSSIBLY DUE TO TREATMENT WITH WYSOLONE (CORTICOSTEROID)

WHITE PATCH OVER TONGUE AND TONSILS

B/l pedal edema

Vitals:

Temperature- Afebrile

BP- 150/100 mm Hg

PR- 114bpm

RR- 30cpm

SpO2- 93% @ RA

Fever charts:

INFERENCE: MULTIPLE FEVER SPIKES SEEN

SYSTEMIC EXAMINATION

Respiratory system examination:

A. Inspection

Symmetrical chest
Decreased air entry on right side
V shaped line seen below the neck
No dilated veins or scars visible

B. Palpation

No lymph nodes palpable
Tactile vocal fremitus increased In lower part of right lung
Trachea centrally positioned
Apex beat felt at the 5th intercostal space along the mid-clavicular line

C. Percussion

Dull note over right infrascapular region, all other regions are resonant

D. Auscultation

Normal vesicular breath sounds heard
Decreased air entry in right infrascapular ,right mammary and inframammary areas

OTHER SYSTEMS:

CNS-

HIGHER MENTAL FUNCTIONS:Normal

Patient is Conscious, well oriented to time, place and person, co-operative

cranial nerves - intact

Motor system

Right. Left

BULK

Upper limbs. N. N

Lower limbs N. N

TONE

Upper limbs. N. N

Lower limbs. N. N

POWER

Upper limbs.

Biceps. 5/5. 4/5

https://youtu.be/KneHsSaJjes

https://youtu.be/l7WoaYVHMlI

Triceps 5/5. 4/5

https://youtu.be/U-Ut0REev8A

Brachioradialis. 5/5. 5/5

Deltoid. 5/5. 5/5

https://youtu.be/QJY6gvjw1ko

https://youtu.be/MyIMyVeO63M

Lower limbs

Gluteus maximus 3/5. 3/5

Gluteus minimus and medius

3/5. 3/5

Iliopsoas. 4/5. 3/5

Quadriceps femoris 4/5. 3/5

https://youtube.com/shorts/w5NfNpVayK8?feature=share

Hamstrings. 4/5. 4/5

Gluteus maximus

Iliopsoas

https://youtube.com/shorts/1lyezZVI_3o?feature=share

https://youtube.com/shorts/yWnhgah3r4c?feature=share

Superficial reflexes and deep reflexes are present , normal

Gait is normal

No involuntary movements

Cerebellar signs- negative

Sensory system - all sensations ( pain, touch, temperature, position, vibration sense) are well appreciated .

CARDIOVASCULAR SYSTEM

INSPECTION:

Chest wall - bilaterally symmetrical

No dilated veins, scars, sinuses

Apical impulse and pulsations cannot be appreciated

PALPATION:

Apical impulse is felt on the left 5th intercoastal space 2cm away from the midline.

No parasternal heave, thrills felt.

PERCUSSION:

Right and left heart borders percussed.

AUSCULTATION:

S1 and S2 heard , no added thrills and murmurs heard.

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

PROVISIONAL DIAGNOSIS:

DERMATOMYOSITIS WITH RIGHT LOWER LOBE CONSOLIDATION AND PULMONARY NOCARDIOSIS.

CHEST X RAYS:

January 2022:

15 March 2022:

26th March 2022:

28th March 2022:

INFERENCE: RIGHT LOWER LOBE CONSOLIDATION.

ECG:

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.

PFT REPORT ON 16/3/22:

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

COMPLETE URINE EXAMINATION:

ALBUMIN-TRACE

SUGAR-NIL

PUS cells-2-3

EPITHELIAL cells: 2-3

SPUTUM CULTURE on 29.03.2022:

Since patient was having cough with sputum which was moderate in amount and whitish yellow in colour, sputum was sent for culture.

Presence of branching and filamentous thin, long, slender AFB resembling Nocardia seen under microscope from sample of both lungs.

Impression : NOCARDIA SPECIES

BRONCHOSCOPY 29.03.22

Sensitive antibiotics were started but suboptimal response was obtained hence a doubt was raised if the Nocardia was cultured due to some contamination of the plates , and hence BRONCHOALVEOLAR LAVAGE was done.

https://m.youtube.com/watch?v=Q4L1HcPtI9o&feature=youtu.be