MD EXAM----->SHORT CASE-2

 CHEIF COMPLAINTS

40yr female farmer by occupation came with complaint of 

Pain in the both hips (Since 6 months)

Pain in the both hands Finger joints on & off (Since 6months)

HISTORY OF PRESENT ILLNES

Patient was apparently alright 6months back,then she developed pain in the both hip regions which is insidious onset,gradually progressive,aggrevated on walking,getting up from sitting posture,Pain relived on taking medications.

Associated with Pains in the multiple small joints of both hands on and off.No history of early morning stiffness,heel pain.

PAST HISTORY

Patient had history of multiple hospital  admissions due to hypokalemic paralysis over past 3years

1st episode :-In 2020,Pt developed weakness of right lower limb, taken to hospital found out to be potassium low, after correction, she recovered 

Asymptomatic between

2nd episode :-In NOV 2021,Paraperesis,Potassium was low,Recovered after correction

3rd episode : In May 2022,Quadriparesis,Potassium was low,Intubated and connected to ventilator in view of respiratory paralysis.Discharged after 7days

4 Months back patient had burning sensation of both eyes which is aggravated on watching TV,cellphone and excessive thirst(bcz of drying of tongue) associated with left parotid gland swelling.With these symptoms patient came to the hospital, eye examination revealed severe dry eye.In view of connective tissue disorder(?sjogren syndrome), Lower lip biopsy was done.Histopathology report shows lymphocytic infiltration of minor salivary glands

DRUG HISTORY

Patient is started on prednisolone tablets 4months back.She used regularly for 1month then after only during severe pains

FAMILY HISTORY

No similar complaints in the family members

PERSONAL HISTORY

Takes mixed diet,appetite normal,regular bowel and bladder movements,adequate sleep.No addictions

GENERAL EXAMINATION

Patient is conscious, coherent,co-operative.Moderately built and Moderately nourished.

Blood pressure-130/70mmhg,right arm, supine position

Pulse-90/min,regular rythm,normal volume, all peripheral pulses felt

Respiratory rate-20/min

Temperature-98 F

Spo2-98% on room air

Grbs-125mg/dl

No pallor,icterus,clubbing,cyanosis,lymphedenopathy,edema of legs

No raised JVP

HEAD TO TOE EXAMINATION

General Condition - Moderately built and Moderately nourished.

Hair - Thin and slightly greyed. Not easily pluckable or no areas of scarring or non-scarring hair loss. No lesions noted on the scalp.

Eyes - No conjunctival chemosis or injection, No redness or corneal lesions. 

General Head, Neck & ENT - No abnormalities. No lymph node enlargement.

Axial - No apparent spinal deformities

Fingers and Nails - No clubbing or cyanosis.Right little finger shows Flexion at the PIP joint

MUSCULOSKELETAL SYSTEM EXAMINATION

Appendicular Skeleton-Upper limb

Shoulder joint(Both sides)

          1)No tenderness or swelling over the both shoulder joint

                2)Apprehension Test--->Negative

Elbow Joint(both sides)

       No tenderness or swelling over the both elbow joint

Wrist Joint(both sides)

       1)Two thumb technique---No tenderness or swelling

          2)Wrist Flexion and Extension---No tenderness

MCP joint(both sides) 

          1)Squeeze Technique---No tenderness

             2)Applying pressure to joint---No tenderness

Interphalangeal Joint

               1)Four Finger Technique---Tenderness present in the Right 2nd finger PIP joint

APPENDICULAR SKELETON-LOWER LIMBS

Hip joint(both sides)

              1)Trendelenburg Test :-Trendelenburg sign positive both sides of hip

Knee joint(both sides)

                  1)Palpation of knee joint---No tenderness 

Ankle Joint(both sides)

                1)Palpation of bare area of ankle joint---No tenderness

Achilles Tendon(both sides) : No swelling or tenderness

Metatarsophalangeal joint(Both sides)

                    1)Squeeze Technique : No Tenderness

Axial Skeleton

Inspection - No visibly apparent spinal deformities; 

Palpation - Inspectory findings confirmed. No spine tenderness. 

Movements - Atlanto-occipital - Flexion, extension and lateral flexion normal

                      Atlanto-axial - Rotation of head normal

                      Spinal Flexion, Spinal Extension, Lateral Flexion and Rotation are normal

1)Straight leg raising test ---No tenderness

2)Patrick's test

               Mild tenderness in the right side noted    

3)Gaenslen Maneuver ---No tenderness seen

4)Schober's test 

EXAMINATIOIN OF OTHER JOINTS :

1)Temporomandibular Joint---No tenderness, synovial thickening, crepitus

2)Sternoclavicular Joint---No tenderness

EXAMINATION OF OTHER SYSTEMS :

CARDIOVASCULAR SYSTEM

-Elliptical & bilaterally symmetrical chest

-No visible pulsations/engorged veins on the chest

-Apex beat seen in 5th intercostal space medial to mid clavicular line

-S1 S2 heard

-No murmurs

PER ABDOMEN :

-Scaphoid

-No visible pulsations/engorged veins/sinuses

-Soft,non tender, no guarding and rigidity, no organomegaly

-Bowel sounds heard

CENTRAL NERVOUS SYSTEM

-Higher mental functions intact

-Cranial nerves - intact

-Sensory system-normal

-Motor system -normal

-Gait --- Waddling Giat + 

   Gait video

PROVISIONAL DIAGNOSIS

Primary Sjogren  Syndrome 

 

Extra glandular Manifestation(Spondyloarthropathy)

Hypokalemic Periodic Paralysis

INVESTIGATIONS

 Chest x ray

     

X ray B/L wrist 

 X ray pelvis

ECG

Hemogram

HB - 8.0gm/dl

Total count - 7,500

Neutrophil - 62

Lymphocytes - 28

Eosinophil - 02

Monocytes - 08

Basophils -00

PCV -26.6

MCV- 80.4

MCH- 24.2

MCHC - 30.1

RDW cv  - 21.6

RBC count - 3.31million/cumm

Platelets - 2.56 L/cu mm

RBS - 101mg/dl

CUE 

PH - 7.0

Color - pale yellow

Appearance - clear

Reaction - acidic

Specific gravity -1.01

Albumin - trace

Sugars - nil

Bile salts - nil

Bile pigments - nil

Pus cells  : 3-4

Epithelial cells : 2- 3

RBC - nil

Crystals - nil

Casts - nil

RFT 

Urea - 16mg/dl

Creatinine - 1.3mg/dl

Uric acid - 3.1 mg/dl

Calcium - 10.1mg/dl

Phosphorus - 2.6mg/dl

Sodium - 141mEq/L

Potassium - 3.6 mEq/L

Chloride - 105 mEq/L

LFT

Total bilirubin - 0.67mg/dl

Direct bilirubin - 0.12mg/dl

SGOT - 14 IU/L

SGPT -11 IU/L

Alkaline phosphatase - 492 IU/L

Total proteins - 6.6 gm/dl

Albumin- 4.02gm/dl

A/G ratio 1.56

ESR - 30mm/ 1st hour

ABG

    PH------>7.22

    Pco2---->24.2

    Po2------>98

    Hco3----->9.7

FINAL DIAGNOSIS

Primary Sjogren  Syndrome 

 

Extra glandular Manifestation(Spondyloarthropathy)

Microcytic Hypochromic Anemia(?Nutritional)

Hypokalemic Periodic Paralysis

Distal Renal tubular Acidosis