19100006009 CASE PRESENTATIONS
LONG CASE:
29/F ,homemaker , unmarried, hailing from chityal, who completed her bsc botany came with complaints of lethargy ,since 6 months.
History of presenting illness:
patient was apparently asymptomatic 6 months back , when she started developing pedal edema on and off upto ankle, subsided on taking rest and elevating limbs, easy fatiguability on doing daily chores like cooking, cleaning the house.
not associated with ,chest pain, shortness of breath, giddiness,loss of appetite,weight loss.
past history:
12 years back , one afternoon during bathing she suddenly couldnt talk,or move her right upper and lowerlimb,with deviation of angle of mouth to the left ,upon which she made sounds , her mother who was nearby came to her aid ,and she was taken to hospital in nalgonda within an hour,and referred to gandhi hospital where she was admitted for 20 days,during which her speech returned and she was able to lift her right upperlimb and walk without support, but still has limp on walking and restricted activity with right hand ,like unable to hold objects,stretch out.
this episode was not associated with blurring of vision, vomiting,headache,loss of consciousness, tingling ,numbness, involuntary movements, swallowing difficulty
Neuro- imaging was done,
she was given one prbc transfusion , started on asprin 150 mg and prednisolone 10 mg which she used for 2 months, and dicontinued treatment on advice of local ayurvedic doctor,she did not follow up thereafter.
3 years back in 2019 she presented to Kamineni narketpally with complaints of painful swelling in the left side of the neck, for which usg guided fnac was done showing granuloma,started on ATT and used for 6 months.
there was no history of fever,malaise,loss of weight, myalgias, loss of appetite,swelling in other areas,night sweats,chronic cough or shortness of breath, claudication pain in limbs.
No h/o hypertension, coronary artery disease.
menstrual history:she had history of menorrhagia for 3-4 years at the age of 15-17 ,later on regular cycles ,pads 3 per day for 5 days.
Family history:No similar complaints in the family, she has two other younger sisters
Personal history: appetite is normal, diet consists of lentils,rice, vegetables, less of meat,eggs ,fruits.,she has normal sleep pattern.
General examination:
built: moderate
nourishment:moderate
Pallor:++
icterus-absent
lymphadenopathy:+ posterior cervical ,single lymph node ,mobile,non tender
cyanosis:absent
clubbing:absent
koilinochya:absent
Pedal edema:absent
contracture present at the right metacarpophalangeal joint.
Pulse
Rate:104/minute
rythm: normal
volume: normal
condition of the vessel: normal
Right. left
carotid. + +
subclavian. +. absent
brachial. +. absent
radial. +. absent
femoral. +. +
popliteal. +. +
posterior tibialis. +. +
dorsalis pedis. +. +
radio femoral delay. not present
bruit:. heard over abdominal aorta,left carotid artery
Blood pressure
upper limb 120/60mmhg. not recordable
lowerlimb. 100 mmhg systolic. 100 mmhg
Systemic examination
CENTRAL NERVOUS SYSTEM
Right/left handed person :initially right,then learnt to write with left hand since 12 years
Education: BSC botany
Higher mental function
conscious
oriented
memory: intact
immediate
recent
remote
speech:
comprehension:+
fluency+
repetition+
reading+
writing+
naming objects+
cranial nerves. right. left
1-olfactory: present. present
2-visual acuity: normal. normal
visual field: confrontation method: normal
colour vision: normal
Fundus: normal. Normal.
3,4,6
eyelids :. normal. normal
position of eyeball at rest: normal. normal
extraocular movements :. normal. normal
pupil :size, shape normal. normal
direct and indirect light reflex: present. present
5:sensory:touch. present. present
pain. present. present
temperature. present. present
motor: side to side jaw movement normal
reflexes: corneal. present. present
jaw jerk. present. present
7th-
motor-frontalis. normal. normal
orbicularis oculus: normal. normal
orbicularis oris: deviated to the left
buccinator:. decreased. normal
sensory: taste:. normal. normal
8th: rinnie's. normal. normal
Weber's :no lateralization
9th,10th-
position of uvula: central
https://youtube.com/shorts/4ZUBBKsDUlE?feature=share
gag reflex present. present.
11th- scm-. normal. normal
trapezius-. normal. normal
12th-
tongue: size, symmetry,
normal. normal
MOTOR SYSTEM:
attitude of limbs: upper limb. Normal
Semi- Flexion at elbow
semi pronated
Thumb tucked into palm
lowerlimb.
Semi -flexed at knee. normal
bulk:arm:
forearm:. 24cm. 25cm
thigh:. 38cms. 39cms.
tone: Right. left
upperlimb. increased normal
lowerlimb. increased. normal
https://youtube.com/shorts/TOgT5HdFHv4?feature=share
https://youtube.com/shorts/y4X2Iv28vD4?feature=share
power:
1)Neck:. flexors:. normal. normal
extension:. normal. normal
2) shoulder: supraspinatus. 4-/5. 5/5
Deltoid:. 4-/5. 5/5
Infraspinatus:. 4-/5. 5/5
Latissimus dorsi :4-/5. 5/5
serratus anterior: 4-/5. 5/5
Pectoralis major:. 4-/5. 5/5
Rhomboids 4-/5. 5/5
3)elbow: biceps. 4-/5. 5/5
Triceps. 4-/5. 5/5
Brachioradialis. 4-/5. 5/5
4) wrist : flexor carpi radialis 3/5. 5/5
flexor carpi ulnaris. 3/5. 5/5
extensor carpi radialis longus:3/5. 5/5
extensor carpi ulnaris longus. 3/5. 5/5
extensor digitorium 3/5. 5/5
handgrip. 60%. 100%
Abductor pollicis longus. 3/5. 5/5
Abductor pollicis brevis. 3/5. 5/5
Extensor pollicis longus. 3/5. 5/5
Extensor pollicis brevis. 3/5. 5/5
Opponens pollicis. 3/5. 5/5
Adductor pollicis. 3/5. 5/5
Lumbricals 2/5. 5/5
Interossei -dorsal. 2/5. 5/5
palmar. 2/5. 5/5
5)Trunk:abdominal
beevor's. absent
Hip: iliopsoas. 4+/5. 5/5
Adductor femoris. 4+/5. 5/5
Gluteus medius 4+/5. 5/5
Gluteus Maximums. 4+/5. 5/5
6)knee: flexion: hamstrings. 4+/5. 5/5
extension: quadriceps 4+/5. 5/5
7) ankle: plantar flexion:. 4-/5. 5/5
dorsiflexion:. 4-/5. 5/5
Reflexes:
superficial
corneal. present. present
abdominal. present. present
plantar:. extensor. flexion
deep:
biceps. 3+. 2+
supinator. 2+. 2+
triceps. 3+. 2+
knee jerk. 3+. 2+
ankle jerk. +1. +1
No clonus
Sensory:. in all dermatomes
fine touch. present. present
joint position. present. present
vibration. present. present
crude touch. present. present
pain. present. present
temperature. present. present
Romberg's test: negative(no sway)
cerebellum:
finger nose. normal. normal
finger finger. normal. normal
knee heal. normal. normal
rebound phenomenon- absent
tandem walking. - normal
Gait:
https://youtube.com/shorts/dK3CpEx0TVM?feature=share
circumduction on the right,
Toes touching the ground first
pace:normal
falling to sides:absent
hand swing:. absent present
turn:. normal
autonomic nervous system:normal
meningeal signs:absent
CVS:
Apex beat: 5th intercoastal space ,2cms medial to mid clavicular line
No parasternal heave
S1 and S2 heard in all areas.
Respiratory System:
Normal vesicular breath sounds heard in all areas.
GIT:
No tenderness or organomegaly
No evidence of free fluid.
Investigations:
2010
Hb: 7.5gm/dl,TLC-8500 cells/mm3, adequate platelets
Ana:negative
2d echo:normal
Serum creatinine:0.9mg%
Peripheral smear:
2018 Update of the EULAR recommendations for the management of large vessel vasculitis
58/M , welder by occupation, hailing from miryalguda ,
came with chief complaints of giddiness since 3 days .
h/o present illness
he was apparently asymptomatic 3 days back when he developed giddiness which is gradual in onset, rotational, episodic, lasting for 30 sec to 1 min, more on getting up from the bed or turning towards the right side, resolved spontaneously., increasing in frequency since 3 days , as he took leave from working and preferred to take more rest .
not associated with syncope,headache,hearing loss, nausea,vomiting, chest pain, blurring of vision,neck pain, sweating, palpitations,weakness of limbs, swallowing difficulty,
past history: no similar complaints in the past
no history of diabetes , hypertension,cerebrovascular disease, coronary artery disease.
Personal history:
Drug history: intermittent use of pantoprazole 40 mg for symptoms of belching ,bloating sensation especially after alcohol
Addictions: alcohol - whiskey 90 ml once or twice in one week for 30 years.
smoker- 5-6 ciggarattes per day for 20 years.
General examination:
pallor:absent
icterus:absent
cyanosis:absent
clubbing:absent
lymphadenopathy:absent
edema:absent
PR-82/min, regular
BP-140/80mmg in right arm
supine and standing
Examination for giddiness
Dix Hallpike :
sypmtoms reappeared with a latency of 15-20 seconds on the right side
1) HINTS
head impulse: corrective saccades+on turning head to the right.
Nystagmus: absent.
Test of skew: negative in both eyes.
Higher mental functions: Intact
CRANIAL NERVE EXAMINATION:
1st : Normal
2nd : visual acuity is normal
visual field is normal
colour vision normal
3rd,4th,6th : pupillary reflexes present.
EOM full range of motion present
5th : sensory intact
motor intact
7th : normal
8th : Weber's:no lateralization
Rinnie's: normal.
9th,10th : palatal movements present and equal.
11th,12th : normal.
Cerebellum:
Tone of limbs:normal
no involuntary movements
finger nose test : able to perform both sides
finger finger test:able to perform both sides
knee heal test:able to perform both sides
dysdidokinesia: absent
rebound phenomenon:
pendular knee jerk:absent
https://youtube.com/shorts/zmJGi-29hZk?feature=share
tandem gait:normal
https://youtube.com/shorts/Pqqi6hELDsY?feature=share
Rhomberg's test:negative
Sensory system:
fine touch. present. present
joint position. present. present
vibration. present. present
crude touch. present. present
pain. present. present
temperature. present. present
No orthostatic hypotension.
CVS:
Apex beat:5th ics in mid clavicular line
no heave
S1 and S2 heard in all areas
R.S: normal vesicular breath sounds heard
GIT: no tenderness,organomegaly or free fluid.
Investigations
ECG:normal sinus rythmn
electrolytes
Sodium-143meq/L
potassium-4.2meq/L
chloride-92
complete blood picture:
hb-12.3 gm/dl
tlc-8200 cells/mm3
plt-2.3 lakh
Management:
Epley's maneuver done- reduction in symptoms observed.
Final diagnosis:
vertigo
secondary to peripheral lesion in the vestibular apparatus.
likely BPPV (benign paroxysmal positional vertigo).
Treatment
Tab vertin 8 mg /po/TID
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SHORT CASE 2:
28 year old married woman, mother of two , from nalgonda ,who does maggam work on blouses ,
came for followup ,
patient was apparently asymptomatic till july 2021, when she first developed low grade fever ,which was present daily,increasing during evening time, for which she took tab dolo 650mg everday for one month, after which she started having joint pains(b/l knee, ankle, elbow, metacarpophalangeal and proximal interphalangeal joints) associated with swelling , with slight restriction of movement for one month.
later she developed oral ulcers,which were painful .
she also had increased hair fall,but no alopecia .
h/o rash over cheeks ? photosensitive
h/o pedal edema pitting type upto ankle.
Her first consultation with a physician was in September 2021 ,where she was adviced to get ana profile done, and was diagnosed with pancytopenia , and started on hcq 200 mg and prednisolone 10 mg twice per day , azathioprine 50 mg which she used for 2 months and discontinued as her joint pains and swelling subsided.
On Jan 1st , she had sudden onset weakness of left upperlimb , which resolved within 6 hours ,not a/w seizures,loss of consciousness.she was started on mycofenolate mofetil 1gm/day which was tapered to 500mg od within 2 weeks, (SLEDAI-14)with followup every two months.
since feb 2022 she has been skipping doses of mycofenolate ,due to financial issues and is taking it three times a week.
Personal history: She has a normal appetite ,consumes grains, Vegetables,meat, and has resumed her work in blouse designing.
menstrual history:
regular cycles 3-4 days /30, 3 pads per day, no clots, missed period for 2-3 months during fever episodes.
General examination:
built:thin
Skin:no hyperpigmentation currently.
pallor: absent
icterus:absent
cyanosis:absent
clubbing :absent
lymphadenopathy:absent
edema :absent
PR: 96/min ,regular
BP:110/70 mmhg
January 2022
Musculo skeletal examination:
Axial skeleton:
1)Cervical spine:normal
2)Thoracic spine:normal
3) Sacro-iliac joint:normal
Appendicular skeleton:
1)Shoulder joint: no swelling
No tenderness
Range of movements: Normal
2)elbow joint: no swelling
No tenderness
Range of movements: Normal
3)elbow joint: no swelling
No tenderness
Range of movements: Normal
4) wrist joint:normal
5) hand: metacarpophalangeal joint:normal
Interphalangeal joint :normal
6) knee joint:no swelling
No tenderness
Range of movements: Normal
7) ankle joint: no swelling
No tenderness
Range of movements: Normal
8) metatarsophalangeal joint:Normal.
Systemic examination
CNS: conscious
Oriented to time ,place,person
Speech: normal
Memory:intact
Intelligence:normal
Cranial nerves:normal
Sensory system:normal
Motor system:normal.
Cerebellum :normal
CVS: Apex beat in 5th ics ,mid clavicular line
S1 and S2 heard in all areas
R.S: bilateral airway entry present,
normal vesicular breath sounds in all areas
GIT:no oral ulcers currently
no tenderness,free fluid , organomegaly.
Investigations
5/8/21--------------------10/10/21--------may 2022
Hb-7.4 gm/dl. 8.9. 11.7
Tlc-3600 cells/cm3. 3400. 6600
platelets -1.9lakh/cm3. 1.84. 3.3lakh
esr-110mm/hr. 10
crp-9.0. negative
RF-negative
peripheral smear -normocytic ,normochromic.
12/12/2021
ana-positive
anti ds dna-strongly positive
anti sm-negative
c3-76.8 mg/dl (low )
c4-normal
As per SLICC criteria (6) in November 2022
clinical-leukopenia, thrombocytopenia,oral ulcers,synovitis
lab criteria-anti dsdna, low complement ,
Current treatment:
Tab. Mycophenolate Mofetil 500mg od
Tab Prednisolone 20mg od
Tab HCQ 200 mg od
Tab. Aspirin 75mg od
Final diagnosis: connective tissue disorder, likely systemic lupus erythematous in remission
(SLEDAI=0)
Criteria for remission
SLEDAI
A score of 4 or more is indicative of active disease.
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Critical appraisal:
Enteric-coated mycophenolate sodium versus azathioprine in patients with active systemic lupus erythematosus: a randomised clinical trial
Ordi-Ros J, et al. Ann Rheum Dis 2017;0:1–8. doi:10.1136/annrheumdis-2016-210882
P-
A total of 240 patients were enrolled between May 2010 and December 2013. Of the patients in this intention-to-treat population, 120 were randomised to each treatment group.
Eligible patients were aged ≥18 years, had an SLE according to the revised ACR classification criteria and moderate-to-severe active disease defined as: a SLE Disease Activity Index 2000 (SLEDAI-2K)26 total score ≥6 or at least 1 British Isles Lupus Assessment Group (BILAG) A or 2 BILAG B domain scores at screening.
exclusion criteria were immunosuppressant therapy 12 weeks before randomisation; active nephritis or non-lupus-related significant laboratory abnormalities.
I-
Eligible patients were randomised (1:1) to receive EC-MPS (target dose: 1440 mg/day) or AZA (target dose: 2 mg/kg, per thiopurine methyltransferase levels (TPMT)) in addition to background oral prednisone and antimalarial agents.
O-
The primary efficacy endpoints were the proportion of patients achieving at 3 and 24 months, at least 8 consecutive weeks of clinical remission (CR), defined as a clinical SLEDAI-2K=0.
Primary endpoint Clinical remission rates were higher in the EC-MPS group by month 3 (32.5% (39/120 patients)) compared with the AZA group (19.2% (23/120); percentage difference 13.3% (95% CI 2.3 to 24), p=0.034) and sustained throughout the study to month 24 (71.2% (84/118) vs 48.3% (57/118); percentage difference 22.9% (95% CI 10.4 to 34.4), p<0.001)
Secondary endpoints included: the overall proportion of patients in CR and partial clinical response (PR) (≥50% reduction in the total SLEDAI-2K score with a BILAG C score or better, without new BILAG A/B scores); treatment failure (premature discontinuation necessitated by protocol-prohibited rescue therapy due to worsening or persistent disease activity
BILAG A/B flares were more common in the AZA group (71.7% (86/120 patients)) compared with the EC-MPS group (50% (60/120)) (p<0.001).
In the AZA and EC-MPS groups, 34.2% and 35% patients had 1 disease flare; 21.7% and 13.3% had 2 flares; and 16.7% and 5% had >2 flares, respectively.
Mucocutaneous and renal flares were more frequent in the AZA group (p=0.003 and p=0.031, respectively)
Flares were associated with medication reduction in 38 patients (31.7%) of the AZA group and 29 (24.2%) of the EC-MPS group.
Rates of new BILAG A flares were low, but significantly higher in AZA (21.7% (26/120) vs 8.3% EC-MPS (10/120), p=0.004)
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