A CASE WITH PAINFUL SKIN LESIONS PRESENTED IN SUMMER 2023

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I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and providing treatment best to our skills and wisdom. 

A 35 year old female , daily wage worker  by profession  came to the opd with chief complaints of painful skin lesions on B/L upper and lower limbs since 2 months   . 

Date of admission: 12/09/23

CHIEF COMPLAINTS 

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

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 with no aggravating and relieving factors . Vesicles later ruptured and discharge was purulent . 

Not associated with itching , burning 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. 

Not associated with pain or any swelling. 

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 , micturition normal . 

➤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 , well known with time, place, person 

She is thin and undernourished.

Ht - 5 feet 

Wt - 27 kg 

Pallor :  Seen 

➤Icterus : Not seen 

➤Cyanosis : not seen 

➤Clubbing : not seen 

➤Lymphadenopathy : not seen 

➤Edema : not seen . 

VITALS

➤  Afebrile 

➤PR : 102beats 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 

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

Margins - irregular , non healing 

Edges - everted , hypopigmented 

Surrounding skin: intact , sensations present.

Floor : Pale granulation tissue present .

Hallux valgus with subluxation of PIP

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 .

PALPATION

➤Liver , spleen not palpable.

➤ No tenderness . 

CENTRAL NERVOUS SYSTEM EXAMINATION

➤Conscious and coherent 

➤Speech : Normal 

➤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              5.0gm/dl                           4.3gm/dl 

TLC.           3650cells/cc                   3000cells/cc

PCV.           16.9.                           14.6

RBC.           2.45mi cells/dl         2.09mi cells/dl

PLT.            5.15lakh/dl               4.0lakh/dl

 

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 : 1.1 mg/L

Serum Na+ - 134 mEq/L

Serum K + - 3.3 mEq/L

Serum Cl -  - 97 mEq/L

Serum Ca2+  - 1.2 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) 

9.  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 .