2. CASE PRESENTATION
Presented by :-
Dr. Mukesh Prasad Gupta
On behalf of
The Department of Medicine
Dhaka central international medical college & hospital
3. Particulars of the Patient
• Name : Mrs. Sonia
• Age : 34 year
• Sex : Female
• Religion : Islam
• Nationality : Bangladeshi
• Occupation : Housewife
• Address : Aminbazar , Gabtoli
Dhaka
• Date of Admission :o5/12/21
This Photo by Unknown author is licensed under CC BY.
4. Chief Complaints:
1. Fever for 2 days
2. Generalised weakness for 15 days
3. Pain in multiple joints for 15 days
What are the Possibilities?
5. History of Presenting Illness :
According to the statement of the patient, she was reasonably well 15 days
back. Then she developed pain in multiple joints of both upper & lower limbs,
mostly involving wrist, elbow, knee & ankle joints. Pain persisted throughout
day & night and more marked in the morning, associated with morning
stiffness which didn’t relieve by taking rest but by painkillers. She also felt
pain in standing from sitting position.
She also complained of fever for 2 days which was high grade, intermittent,
associated with chills and rigors and the highest recorded temperature was
103 F. Fever subsided by taking Paracetamol.
She also complained of generalized body weakness for 15 days.
This Photo by Unknown author is licensed under CC BY-SA.
6. Contd..
She also complained of rash in whole body and mild itching when
exposed to sunlight and loss of scalp hair for 1 year.
She also complained of weight loss which was evidenced by loosening of her
clothes and occasional cough with breathlessness when exposed to cold,
dust and pollens especially during winter seasons.
On further query, the patient also mentioned that she was admitted to a
hospital 9 months back with high grade fever ,generalized weakness, body
ache, oral ulcer and low BP. She was in ICU for 3 days. She was later
discharged with management of her condition & advices.
This Photo by Unknown author is licensed under CC BY-SA.
7. This Photo by Unknown author is licensed under CC BY-SA.
Contd…
She did not give any history of bleeding ,convulsion ,unconsciousness, night
sweat, pain in abdomen or chest ,palpitations ,burning micturition.
She is a known case of hypothyroidism and bronchial asthma.
Her bladder habit was normal but she complained of constipation.
She is normotensive & non diabetic.
8. HISTORY OF PAST ILLNESS :
She was diagnosed with Pulmonary Tuberculosis 21
years back and treated as per DOTS category-1
regimen for 6 months.
She also had a history of abortion 2 years back.
9. Drug History
Regular medications:
Tab Thyrox (Levothyroxin Sodium ) 50 mg 1+0+0
Tab Reconil (Hydroxychloroquine Sulphate) 200mg 1+0+1
Tab Cortan 20mg ( Prednisolone ) ½ +0 +0
Tab Marincal D (Calcium + Vit-D3) 1+0+1
Tab Phenocept ( Mycophenolate Mofetil) 500mg 1+0+2
Tab Montair ( Montelukast ) 10mg 0+0+1
Tab Doxiva ( Doxophylline ) 200mg 1+0+1
Tab Bicozin (Vit-B complex + Zinc ) 1+0+1
She has no known allergy to any drugs.
This Photo by Unknown author is licensed under CC BY-NC.
10. PERSONAL
HISTORY
She is a non-smoker ,non-
alcoholic ,non-betel nut
chewer.
This Photo by Unknown author is licensed under CC BY-SA.
This Photo by Unknown author is licensed under CC BY-SA.
11. Family History
All other members of her
family are apparently healthy
(Father,Mother,Brother,Sister ,
Children)
13. Socio-economic
History
She belongs to middle
class family .She lives in a
2-storeyed brick house
with safe water supply.
This Photo by Unknown author is licensed under CC BY.
14. MENSTRUAL HISTORY
She was amenorrhoeic for last 2 months and her menstrual
cycle was irregular.
16. General Examination
Appearance : Ill-looking with cannula in situ in right hand
Body built : Average
Body hair distribution: Alopecia
Cooperation : Cooperative
Decubitus : On-choice
Nutritional status : Average
Anemia : Moderately Anemic
Jaundice : Absent
Cyanosis: Absent
20. Musculo-skeletal System
There was no visible swelling and deformity of any
joints.
There was no muscle wasting.
Temperature over the joints were normal but there
was slight tenderness.
21. Respiratory System
Inspection:
Shape of chest normal, no deformity.
Palpation:
Trachea is central in position.
Apex beat is on left 5th intercostal space.
Percussion:
Percussion note is resonant.
Auscultation:
Breath sound vesicular
No added sound
22. Abdominal System
Inspection
Shape of abdomen – scaphoid
Flank – not full
Umbilicus - centrally placed & inverted
Palpation
There was no tenderness on superficial palpation .
Deep Palpation :
Liver, spleen were not palpable
Kidney wasn’t ballotable
Renal angle wasn’t tender
24. Cardiovascular System examination : revealed no abnormality
Nervous System examination : revealed no abnormality.
25. Salient Features:
Mrs. Sonia, 34 year old, normotensive, non-diabetic female
hailing from Aminbazar , Dhaka got admitted to this hospital with
the complaints of fever for 2 days, pain in multiple joints and
generalized weakness for 15 days. Fever was high grade,
intermittent and associated with chills and rigor which subsided
after taking paracetamol.
Joint pain was associated with morning stiffness and didn’t relieve
by taking rest but by painkillers. She also complained of rash in
whole body and mild itching when exposed to sunlight and loss of
scalp hair for 1 year.
26. Cont…
On examination, patient was ill-looking with cannula in situ in right
hand, moderately anaemic , alopecic, pulse : 135 beats/min, BP :
90/60 mmHg, temperature: 101° F and respiratory rate : 18
breath/min. Musculo-skeletal system revealed slight tenderness
over knee, ankle and wrist joints. Other systemic examinations
revealed no any abnormality.
53. Advice on discharge
Take medicines regularly .
Minimize exposure to direct sunlight.
Use SPF 90 sunblock on regular basis
Do CBC with PBF , CRP, Urine R/M/E , S . Creatinine
tests and visit the consultant after 6 months.
