SCM AFMC

1. SATURDAY CLINICAL
MEET
INTERNAL MEDICINE
UNIT 2
1
SQN LDR PRASHANT KR DIXIT
MODERATOR- WG CDR S KARTIK

2. PERSONAL PARTICULARS
37/M
Serving soldier
Resident of Tezpur, Assam
Educated up to XII standard
Informant- self
Reliability- good
2

3. PRESENTING COMPLAINTS
 Fever 25 days
3

4. HISTORY OF PRESENT ILLNESS
 Fever x 25 days
Low grade
Intermittent
With chills but no rigors
4

5. HISTORY OF PRESENT ILLNESS
Weight loss- 04 kgs
Anorexia
Generalised weakness
5

6. HISTORY OF PRESENT ILLNESS
No history of
Pain abdomen, vomiting, diarrhea, dysuria
Cough/breathlessness, chest pain, syncope
Rash, purpura, petechiae
Headache, neck stiffness, neurological deficit
Raynauds’s phenomena
6

7. HISTORY OF PRESENT ILLNESS
Initially evaluated at a peripheral hospital and
later transferred to this center as a case
Pyrexia of unknown origin
7

8. FURTHER COURSE
Continued to have fever
Developed joint pain over small joints of both
hands during course of illness
8

9. HISTORY OF PRESENT ILLNESS
 Pain over small joints of both hands
VAS -4/10
Early morning stiffness
Swelling
No aggravating/ relieving factors
9

10. PAST HISTORY
No history of DM/HTN/CAD
10

11. PERSONAL HISTORY
Consumes mixed diet
Normal sleep
Normal bowel/bladder habits
No h/o high risk behavior
Alcohol consumer 40-60 g/day x 5 years. Last
alcohol intake 04 months before onset of
symptoms
11

12. FAMILY HISTORY
No h/o similar illness in family
No h/o TB, DM, HTN
12

13. GEN EXAMINATION
Avg built
Ht : 169 cm weight: 64 kg BMI- 22.2
Temp – 100.6o
F
P: 96/ min reg, all peripheral pulses palpable, no
RR or RF delay
BP: 126/80 mm Hg RAS
RR: 16/min
13

14. SYSTEMIC EXAMINATION
Respiratory system
B/L infrascapular end inspiratory crepitations
heard
B/L equal air entry
CVS
S1 and S2 Normal
No S3, S4 or pericardial knock
No murmurs
14

15. SYSTEMIC EXAMINATION
P/A
Soft non tender, no organomegaly
No free fluids, bowel sounds heard
Nervous System
 HMF Normal
 Motor system- Proximal muscle weakness
 Sensory- normal
15

16. MUSCULOSKELETAL
EXAMINATION
Puffy hands
Mechanic hands
Swelling and
tenderness over
small joints

17. MUSCULOSKELETAL
EXAMINATION
Nail Fold
Capillaroscopy –
mild capillary
enlargement

18. INVESTIGATIONS
Parameter Patient Value Normal range
Hb 11.7 15.5 ± 2.5 g/dl
TLC 16700 4000-11000 /cumm
DLC P85 L10 P 40-75, L 20-45, M2-8,
E 0-4, B 0-1
Platelets 4.53 lakhs/cumm 1.50 – 4.00 lakhs/cumm
PBS Normocytic
normochromic
Urine RE/ME NAD
Urine for AFB Negative
18

19. INVESTIGATIONS 19
Parameter Patient value Normal Range
Urea/ Creatinine 23/0.5 10-50 / 0.8-1.4 mg/dl
Na/K 138/3.6 135-145/3.5-5.0 Meq/L
Ca/P 8.7/3.5 8.5-10.2/2.5-4.5 mg/dl
Bilirubin (Total) 0.7 mg/dL 0.1 – 1.0 mg/dl
AST/ALT 164/55 0-40 IU/L
LDH 749 IU/L 140-280 IU/L
Total proteins/ Alb/Glob 6.2/2.3/3.9 g/dL 6-8/3.5-5.5/1.8-3.6 g/dl
CPK 814 U/L 22-198 U/L

20. INVESTIGATIONS 20
Parameter Patient value Normal Range
Iron/TIBC (mg/dl) 82/190 65-180 ug/dl
45-85 umol/L
Widal test
Weil felix test
<1:20(all titres)
<1:30(all titres)
Dengue Negative
HBsAg/Anti HCV/HIV Negative
Mantoux test/Sputum
for AFB
Negative
T3/T4/TSH 64 ng/dl; 5.1 ug/dl; 1.9
uU/ml
80-180 ng/dl; 4.6-12
ug/dl; 0.5-6 uU/ml
Blood culture No growth

21. INVESTIGATIONS
Bone Marrow study- Normal
USG Abdomen(18/06/16)-Normal study
2D ECHO(25/6/16)- LVEF 60%, Normal study.

22. DLCO
Moderate diffusion defect

23. INVESTIGATIONS
CECT Chest/Abdomen(20/6/16)
Interlobular septal thickening. F/s/o Acute
Interstitial Lung Disease.
MRI Thigh(25/06/16)
Findings consistent with myositis- bilateral
thighs.

24. MRI BOTH LOWER LIMBS

25. CECT CHEST/ABDOMEN

26. IMMUNOLOGICAL INVESTIGATIONS
26
Parameter Patient value Normal Range
ESR(mm fall 1st
hour) 45 Male 0-22 mm fall 1st
hour
CRP 14.0 < 5 mg/L
C3 166 79-152 mg/dL
C4 21.5 16-38 mg/dL
RF < 20.0 < 25 IU/mL
ANA Negative
SSA(Ro52/R060) Positive
Jo1 Positive

27. DIAGNOSIS
IDIOPATHIC INFLAMMATORY MYOSITIS
27

28. MANAGEMENT
Pulse Methylprednisone therapy
Oral prednisolone in tapering doses
Tab. Azathioprine 100 mg OD
Tab. Hydroxychloroquine 400mg OD

29. PRESENT STATUS
Afebrile
Joint pain and swelling subsided
Recovered from muscle weakness
Able to carry out daily activities

30. INVESTIGATIONS
Parameter Patient Value Normal range
Hb 13.2 15.5 ± 2.5 g/dl
TLC 5800 4000-11000 /cumm
DLC P65 L30 P 40-75, L 20-45, M2-8,
E 0-4, B 0-1
Platelets 2.53 lakhs/cumm 1.50 – 4.00 lakhs/cumm
PBS Normocytic
normochromic
30

31. INVESTIGATIONS 31
Parameter Patient value Normal Range
Urea/ Creatinine 23/0.5 10-50 / 0.8-1.4 mg/dl
Na/K 138/3.6 135-145/3.5-5.0 Meq/L
Ca/P 8.7/3.5 8.5-10.2/2.5-4.5 mg/dl
Bilirubin (Total) 0.7 mg/dL 0.1 – 1.0 mg/dl
AST/ALT 24/22 0-40 IU/L
LDH 286 IU/L 140-280 IU/L
Total proteins/ Alb/Glob 6.4/3.8/2.6 g/dL 6-8/3.5-5.5/1.8-3.6 g/dl
CPK 28 U/L 22-198 U/L

32. INVESTIGATIONS
Parameter Patient Value Normal range
ESR(mm fall 1st
hour) 14 Male 0-22 mm fall 1st
hour
CRP 4.79 < 5 mg/L
32

33. HRCT CHEST

34. AIM OF PRESENTATION
Discuss approach to PUO and fever with joint
pains

35. Thank you