March 29, 2022

Case discussion of a 30 y/o Female with Dermatomyositis With Pulmonary Nocardiosis

This is 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 a series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective, current, best evidence based inputs.
This e-log book also reflects my patient centered online learning portfolio and your valuable inputs in the comment box is welcome

A case of 30 y/o Female with Cough and Dyspnea

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

ACKNOLEDGEMENTS:

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 to Dr. Simran Ma'am (Intern), Dr. Nikitha Ma'am (Intern) and Dr. Saicharan Kulkarni sir (PG) for guiding me through the case and helping me build this blog.

March 15,2022

30 years old female homemaker by occupation came to the General Medicine OPD with the

CHIEF COMPLAINTS:

B/L joint pains associated with edema over legs from knee to ankle joint including dorsum of foot since 4 days
C/O dyspnea in rest since 4 days
C/O cough 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 DM, HTN, BA, epilepsy, Asthma, CVA, CAD.
Had similar complaints in the past 2 months.

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

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

DAILY ROUTINE OF THE PATIENT :

The patient lives in a family of 3 ..(of late the family has expanded) 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

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

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.

General physical examination

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