36 year old female patient with Multi joint pain

 January 06, 2022

36YEAR OLD FEMALE WITH JOINT PAINS, MALAR RASH, ORAL ULCERS

A 36 years old female patient came with chief complaints  of
Multi joint pain since 2 months ,morning stifness of joints since 1 month ,Menorrhagia since 1 month 

HOPI
Patient was apparently asymptomatic 2 months back, then she had rapid weight gain, menorrhagia, multiple joint pains, she visited a hospital and was found that her TSH was >100 mlU/L and was started on THYRONOME 100 micrograms.
Her menorrhagia subsided, but she continues to have multiple joint pain (all small joints and large joints) associated with swelling of joints, morning stiffness for 30mins, on evaluation she was found to have CRP (+), Hb-10.8gm/dl, Uric acid-7.8 and was started on T. ALLOPURINOL100mg BD.
Her joint pains are associated with on and off low grade fever since 2months, using T.PCM 650mg BD since 2months. 
On Dec 29th:
 ANA- 3.18(if >1.2 strongly positive)
Anti CCP -1.4 UI/ml (Negative)
Rh factor- Negative 
TSH -16.9 (continued on T. THYRONOME 100 micrograms)
Since 5 days Patient tellsthat her joint pains and swellings subsided 
C/O oral ulcers since 20 days
C/O Blackish spots over malar aspect of face since 15days
MRI spine done 3/1/22 - Multiple level disc protussion causing thecal sac indentation and B/L C5-C6 mild neural foraminal stenosis

PAST HISTORY 
K/C/O Hypothyroidism (on T.THYRONORM 100 micrograms)
N/K/C/O DM, HTN, CAD
No previous hospitalisation

O/E
Pt c/c/c
Pallor (+)
No Icterus/cyanosis/koilonychia/generalised lymphadenopathy/pedal edema 
Temp-99.6 F
Pr-115bpm
BP-110/80 mmhg
Rr-21/min
Spo2-98% @RA
GRBS-132 mg/dl
Ulcer over left lateral aspect of tongue
Goitre(+)
Cvs-s1 s2 +,no murmurs
R/S- bae+,nvbs
Cns-no fnd
P/A-soft,nt

PROVISIONAL DIAGNOSIS 
Sero negative arthritis (2° to RA ?SLE) with k/c/o hypothyroidism 

INVESTIGATIONS 


TREATMENT 
T.THYRONORM 100mcg po od bbf
Syp.MUCAINE GEL 10ml po tid
T.RIBOFLAVIN 5mg po bd
T.ZINCOVIT po od
T.PCM 650mg po sos
T.PAN 40mg po od
ZYNTEE gel for l/a
Inj.NEOMOL 1g iv sos (if temp >100°F)
Tab.ULTRACET 1/2 tab qid
Tab.WYSLONE 40mg po od
Temp/BP/PR/SPO2 monitoring 4th hrly

CLINICAL IMAGES 



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