70 yr old female patient ....
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70yr old female came to OPD
C/O
loose stools since 10 days and two episodes of vomiting 10days ago. lower back pain and blebs over dorsal aspect right lower limb along with swelling since 20 days.
NO PURPLE STRIAE
PUFFINESS OF THE FACE
x ray of wrist AP veiw
. Xray of wrist lateral view
Patient was asymptomatic for 15yrs back.
15yrs back H/o fever - on check up found to have HTN
10 yrs back joint pains were developed first to distal small joints ,elbow joint and now many joints are involved ( pt do not have an idea about the sequence of joints involved in pain after that)
8 yrs back pt found that aggravated joints pains went to a local hospital and started to use
Tab ACECLOFENAC
Tab OMNACORTIL 5mg OD tapperd in between again she restarted using OMNACORTIL 5mg OD
as she developed pains again.
5yrs back H/o slip and fell off..and got operated for right tibial implant insitu.
4yrs back underwent tooth extraction.
And also had history of loose stools with
tenesmus with no blood. ago she was admitted in our hospital with the H/o fever and diagnosed with some renal problems (but no records are available)
later she was discharged.
UTI, PYELONEPHRITIS??
1yr ago c/o facial puffiness, generalised weakness,on and off of B/l pedal edema,still with multiple joints pain.
5months back c/o Rt DIP ,PIP,wrist joint pain with restriction of movements ( mainly while eating)
10 days ago c/o blebs over dorsal aspect of right foot later formed a scab along with swelling of right lower limb which is regressed now.
Also a c/o of lower backache along with 5-6episodes of stools/day (large volume,watery consistency)
H/o 2 episodes of vomiting 10 dys ago ,not associated with pain abdomen,fever, burning micturition,cough,SOB
No c/o chest pain , palpitations,giddiness,sweating
Bowel and bladder movements - regular
K/C/O of HTN since 15yrs ( 1 yr on T.TELMAH 80/12.5 mg OD,
H/O chronic Abuse of NSAIDS,steroid abuse for multiple joint pains.
N/K/C/O - DM ,CVA
H/O - reduced appetite since 1yr
Menopause at 40 yrs ago
VITALS
TEMP - 96.6F
PR-100bpm
BP- 100/70 ( not on antiHTN since 4 days)
RR-16/min
SPO2- 98
GRBS-. 87mg / dl
O/E
PHYSICAL EXAMINATION:
NO pallor/ icterus/ cyanosis /clubbing
Generalised lymphadenopathy
Pedal edema present
Cushingoid appearance of face - present
Dry skin - present
No purple striae
L/E
Rt distal interphalangeal joints and proximal interphalangeal joints and wrist are showing tenderness and showing painful ROM
Rt and Lt elbow- normal
B/l shoulders showing painful movement
Lower limbs showing :
Rt LL - Rt knee deformity,
Rt ankle is externally rotated.
Lt LL- normal,no ROM
Systemic Examination :
S1 and S2 are heard
No murmurs
R/S : BAE+, NUBS +
P/N : soft ,non tender,BS +
CNS :
Conscious
Cranial nerves - intact
Sensory system - normal
REFLEXE'S
RT LT
BICEPS 3+ 2+
TRICEPS 3+ 1+
SUPINATOR 2+ 1+
KNEE _ _
ANKLE _ _
Plantar withdrawl withdrawl
PROVISIONAL DIAGNOSIS :
ACUTE GASTROENTERITIS
IATROGENIC CUSHINGS??
ASSYMETRIC POLYARTHRITIS
ANEMIA UNDER EVALUATION
(IDA ,ANEMIA OF CHRONIC).
AKI ?? CKD ? ( secondary to NSAID CHORINC ABUSE).
TREATMENT:
IVF :. 20 s and
10 RL
50 ml / hr
ORS SACHETS 1 sachet in 1 litre water
200 ml of after each stool
T.Prednisolone 5 mg PO OD
Xray of LS spine
