29 Year OLD FEMALE WITH B/L JOINT PAINS SINCE 10 MONTHS.

C/c:

B/L joint pains since 10 months.

B/L muscle weakness since 10 months. 

Itching of hyperpigmented skin lesion around neck and anterior aspect of chest since 10 months .

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 10 months back, she then developed symmetrical b/l joint pains in the knees which was insidious in onset, gradually progressive, no aggravating factors and relieved on medication i.e. TAB. HYDROXYCHLOROQUINE 200 mg 

Associated with morning stiffness.

Patient complaints of pain the gums. 

She also complains of Generalised joint pains.since 10 months. 

Then she developed itching around the neck and anterior aspect of chest. Area was initially red and then turned black. 

She developed similar lesions on her back, malar area of the face, buttoks and loin region.

She have a complaint of generalised muscle weakness associated with pain. Since 10 months. 

Patient complaints of difficulty to squat and bend sideways-weakness of proximal muscles. 

Difficulty in eating and mixing food, combing her hair, difficulty in lifting objects with her hand-associated with pain and action tremors-weakness of distal muscles. 

She have a complaint of B/L pedal edema and B/L swelling on dorsum of hand. Since 10months

History of  Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months,associated with thinning of hair.

History of weight loss over 4 kg over the last 10 months.

History of oral ulcers and genital ulcers since 10 months.

Patient complains of vagina discharge since 8 months. Initially diacharge was curdy white later turned to watery discharge, with lesions in the genital area associated with itching.

PAST HISTORY:

No history of diabetes, hypertension, asthma, epilepsy, tunerculosis.

No history of similar complaints in the past.

FAMILY HISTORY:

 No similar complaints in the family. 

PERSONAL HISTORY : 

 Diet- mixed. 

Appetite- reduced. 

Sleep- Inadequate since 10 months . 

Bowel and bladder habits- Regular. 

No addictions. 

No known drug allergies.

Menstrual history: AOM- 11 years. 

  3/25-28, regular , no pains, no clots.

Marital  history: ML- 14 years, NCM. Primary infertility (Nulligravida). Has recently adopted a girl from her sister-in-law. 

GENERAL EXAMINATION :

Patient was c/c/c, well oriented to time place person,Moderately built ,moderately nourished.

Pallor-present. 

Cyanosis-absent. 

Icterus-absent.

Clubbing-absent.

No lymphadenopathy. 

B/L pedal edema present. 

ON EXAMINATION:

Diffuse erythematous hyperpigmentation rash (Heliotrope rash) noted on B/L cheeks, nose(bridge) involving nasolabial folds, ears, neck extending onto upper chest and back forming a ‘V’ on anterior chest (Shawl sign). 

• Few hyper-pigmented macules noted on mid and lower back (‘V’ sign).

• Single erythematous macule noted over the right loin (Holsier sign).

• Pigmentation of B/L knuckles noted (Gottron’s Papules).

Vitals: 

Temperature- Afebrile. 

BP- 130/80 mm Hg. 

PR- 102 bpm. 

RR- 14 cpm. 

SpO2- 99% @ RA. 

SYSTEMIC EXAMINATION:

CVS- S1, S2 sounds heard. No murmurs. 

RS- BAE+ NVBS heard. 

CNS- NAD. 

P/A- Soft, non tender, Bowel sounds.

INVESTIGATIONS :

SERUM CREATININE-0.6mg/dl.

RBS:116mg/dl.

CRP-NEGATIVE. 

RA FACTOR-NEGATIVE. 

Serology - negative. 

PROVISIONAL DIAGNOSIS:

DERMATOMYOSITIS. 

SLE. 

OPPURTUNISTIC GENITAL CANDIDIASIS AND ORAL ULCERS.

TREATMENT :