A 29 year female patient with complaints of joint pain

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 29 years old female homemaker by occupation came to the General Medicine OPD with the 

Chief complaint:-

   - B/L joint pains (knees) since 10 months

   - B/L itching in the upper aspect of chest and neck since 10 months    

History of present illness: 

 —> Patient was apparently asymptomatic 10 months ago. Then she 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.

— Around the same time she developed itching over neck and upper chest area. As a result of the itching, the area was initially red and turned black. 

— C/O Alopecia since 10 months. It was gradually progressive leading to severe hair loss over the past 10 months. Associated with thinning of hair.

— C/O bilateral pitting type of pedal Edema and Edema over the dorsal aspect of hands.

— C/O generalised pain.

— C/O Difficulty in walking.

— C/O distal muscle weakness manifested in the form of : difficulty in mixing food, eating with hands, buttoning-unbuttoning of shirt, combing of hair.

— C/O proximal muscle weakness manifested in the form of : difficulty in getting up from squatting position, getting objects present at a height.

— C/O Dyspnea on exertion (NYHA- 3), gradually progressive since 4-5 months.

— C/O vaginal discharge since 7-8 months. It was initially curdy white which later changed to watery discharge. Associated with itching. 

— C/O weight loss of 4 kg over the last 10 months.

— C/O oral ulcers and genital ulcers since 10 months.

--No h/o fever, cold, cough.

Past history:- 

Not a known case of DM, HTN, BA, epilepsy, Asthma, CVA, CAD.

— No similar complaints in the past. 

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. 



Family h/o:- 

—No similar complaints in the family

Personal h/o:-

  Diet- Mixed

  Appetite- Decreased

   Sleep- Inadequate since 10 months

    Bowel and bladder habits- Regular

     No addictions

     No known drug allergies 

General physical examination:- 

The patient is conscious, coherent, cooperative well oriented to time, place and person. She is moderately built and moderately nourished. 

Pallor- present
No icterus, cyanosis, clubbing, lymphadenopathy.

Pedal Edema- present 

O/E:
Diffuse mottled erythematous hyperpigmentation (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).

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