A case of painful skin lesions

A 35 years old female , daily wage worker  by occupation came presented with chief complaints of painful skin lesions on B/L upper and lower limbs since 2 months, fever and burning micturition since 4days. 

Date of admission: 12/09/23

CHIEF COMPLAINTS 

➤ Painful  skin lesions over both hands and legs since 2 months . 

➤Fever since 4 days

➤Burning micturition since 4 days


HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 months back. Then she developed complaints of painful skin lesions over the arms and the legs , which was sudden in onset , progressive , no aggravating and relieving factors . Vesicles later ruptured with purulent discharge

Not associated with itching , fever and redness.

Fever since 4 days coming on alternate day not associated with chills and rigor, diurnal variation, relieves with medication. 

Burning micturition since 4 days. Not associated with increased frequency /urgency /hesitancy/decreased urine . 

H/o deformity of hands , toes and fingers since 16years which was sudden in onset and progressive  after which she went to local doctor and took medication for the same but later stopped taking the medicines and carried on with her normal daily routine( as a daily wage worker) and deformity progressed. 

no complaints of loss of function in either of the limbs. 

No h/o breathless, palpitations, orthopnoea, PND, no known comorbidities. 

 PAST HISTORY

➤ No similar complaints in the past 

➤ Not a k/c/o Diabetes mellitus , Hypertension, TB, epilepsy , asthma ,CAD , thyroid disorders , CVA.

➤ No history of blood transfusion.

➤ No surgical history .


PERSONAL HISTORY

➤Occupation: Daily wage worker 

➤Patient is married .

➤Patient takes a mixed diet and has normal appetite.

➤Sleep : Regular 

➤Bowel movements are regular , 

➤Bladder movement- Regular with burning micturition 

➤No known allergies .

➤ No known addictions .

➤ Menstrual history 

       Age of menarche : 13 yrs 

       Cycle duration : 30 days of cycle 

       No of days of bleeding : 3 days 

        LMP : 23/08/23   


➤ Obstetric history 

       Age at marriage : 18yrs 

       Age at 1st child birth : 18 yrs (FTND) 

 


 FAMILY HISTORY 


Not significant .

                           

GENERAL EXAMINATION


Patient is conscious ,coherent , cooperative , 

She is thin and undernourished.

Ht - 5 feet 

Wt - 27 kg 


Pallor :  Seen 








➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : not seen . 



VITALS


➤  Afebrile 

➤PR : 102 beats per minute

➤BP : 70/60 mm Hg

➤RR : 18 cycles per minute

➤SpO2 : 98% in room air

➤ GRBS : 104 mg/dl 


SYSTEMIC EXAMINATION


JOINT FINDINGS 

Non tender hard nodule over DIP joint of middle and index finger 


Flexion at DIP joint and hyperextension at PIP joint(swan neck deformity) 
Hallux valgus with subluxation of PIP



O/E Multiple polysized ulcers noted over B/L hands ,elbows, B/L legs , dorsum of foot

margins: irregular, non healing
sensation intact, surrounding skin : normal
floor: pale granulation tissue

 




CARDIOVASCULAR SYSTEM EXAMINATION

➤s1 and s2 heard

➤Thrills absent

➤No cardiac murmurs



RESPIRATORY SYSTEM


➤Normal vesicular breath sounds heard.

➤Bilateral air entry present

➤Trachea is in midline.

➤ Breath sounds - vesicular 


ABDOMINAL EXAMINATION

INSPECTION

➤Shape - Scaphoid 

➤Equal movements in all the quadrants.

➤No visible pulsation and

localized swellings , hernial orifices intact . 

➤Umbilicus: Normal .


CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent 

➤Speech : Normal 

➤No focal neurological deficient 

➤No signs of meningeal irritation 


PROVISIONAL DIAGNOSIS: ? Cystitis IDA SECONDARY TO RHEUMATOID ARTHRITIS (? PYODERMA GANGRENOSUM) 


INVESTIGATIONS 


1. Hemogram 


                  12/09/23.                   13/09/23            

Hb              5.0.gm/dl                            4.3 gm/dl

WBC          3650cells/mm3                       3000

PCV.           16 %                                               14.6

RBC.           2.45mill. cells/mm3                  2.09

PLT.            5.15.lakh/mm3                       4.0 

 

2. Complete Urine Examination

Albumin :   Present.                 

Sugar :        Nil.                        

Bile salts/pigments :  Nil 

Pus cells : Plenty 

RBC : 20-25cells 

Casts : Nil


3. RFT 

Blood urea : 37mg/dl

Serum Creatinine : 1.1mg/dl

Serum Na+ - 134meq/l

Serum K + - 3.3 meq/l

Serum Cl -  - 97 meq/l


4. Serology 

HCV - Negative 

HBsAg - Negative 

HIV - Negative 


5. RBS - 89mg/dl


6. CRP - Positive (2.4mg/dl) 


7. RPR - Non reactive 


8. RA - Positive (24.10 IU/ml) 

USG





TREATMENT


1. IV fluids NS at 30ml/hr 

2. Tab Augmentin 625mg PO TID 

3. Tab. Pantop 40 PO OD 

4. Tab. Paracetamol 650 mg PO SOS 

5. BP monitoring hourly .



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