36YEAR OLD FEMALE WITH JOINT PAINS, ORAL ULCERS

GENERAL MEDICINE CASE

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G. AISHWARYA

ROLL NO- 35

    A 36 years old female patient came to OPD.

CHIEF COMPLAINTS:

• Multiple joint pains since 2 months

• Oral ulcers since 20 days

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 2 months back, then she developed multiple joint pains of upper and lower limbs and menorrhagia 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 is present.On evaluation she was found to have CRP (+), Hb-10.8gm/dl, Uric acid-7.8 and was started on T. ALLOPURINOL100mg BD.

 Associated with

•  Low grade fever on and off since 2months, using T.Paracetemol 650mg BD since 2months. 

• Oral ulcers since 20 days

• Blackish spots over malar aspect of face since 15 days

DAY 8:

• 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 

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,co operative.

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

Ulcer over left lateral aspect of tongue

Goitre(+)

SYSTEMIC EXAMINATION:

CVS :s1 s2 +,no murmurs

R/S- bilateral air entry positive, normal vescicular breath sounds.

Cns- no focal neurological deficit.

P/A-soft,non tender, no organomegaly present.

PROVISIONAL DIAGNOSIS 

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

INVESTIGATIONS:

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

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.