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Chief Complaints
1. Thickening, tightening and
swelling of the skin for 3
months
2. Multiple joint pain for 3
months
3. Burning sensations in chest
& abdomen with difficulty in
swallowing for 3 weeks
Treatment History
She took several drugs for her
recent illness before being
admitted to this hospital but she
could not mention the name of
those drugs.
She gave no history of drug
allergy.
Personal History
She does not chew betel nut.
She is a non
smoker.
Family History
Her father is suffering from
rheumatoid
arthritis. Other members are
healthy.
Socio-economic History
She came from a middle class
family
She used to drink tube well
water
Travel History
She had no significant travel
history
Immunization History
Immunized
Menstrual History
She is a regular menstruating
woman. But
recently she noticed very poor
flow lasting for
1 day only.
Obstetric History
She is having 3 children. All of
them are
healthy.
General Examination
Clubbing: Absent
Koilonychia: Absent
Leukonychia: Absent
Dehydration: Absent
Oedema: Present, pitting
Pulse: 80 bpm
BP: 110/80 mmHg
Respiratory rate: 18 b/min
Thyroid gland : Not enlarged
JVP : Not raised
Lymph node: Not palpable
Skin examination
Extremities
Non-pitting edema of fingers,
wrists (Flexor tendon sheaths),
forearms, legs, ankles, feet, face
and neck.
Shiny, thick and tight skin. Distal
skin creases was disappeared. No
erythema or telangiectasia.
There is generalized
Systemic Examination
Musculoskeletal System
Hands
There was scleroductyly with the
skin of
both hands being smooth, shiny,
tight, thick
and oedematous with
hyperpigmentation.
No telangiectasia was found.
Joints
No swelling, redness, warmth or
deformity was present.
Muscles
No tenderness or wasting was
present.
Abdomen Examination
Inspection
Shape of the abdomen:
Scaphoid
Umbilicus: Centrally placed &
inverted
No engorged veins, visible
pulsation in
epigastrium/peristalsis was
present
Palpation
Soft.
No tenderness, muscle guard
or rigidity & organomegaly, no
tender hepatomegaly, no
shifting dullness or fluid thrill.
Percussion
Tympanic.
Auscultation
Bowel sound was present.
Respiratory Examination
Breath sound is vesicular.
There is no added sound.
Cardiovascular system
examination
No left parasternal heave,
palpable/loud P2
Salient features
Mrs. Josna Begum, 35yrs old, housewife,
married women hailing from Bishwanath,
Sylhet, non-diabetic, non-hypertensive
admitted in this hospital on 2nd may 2015
with the complaints of intermittent
burning sensation in fingers of both
hands for 6 months; gradual thickening,
tightening of skin of both of her forearms,
wrists, hands, legs, ankles, feet as well as
face and neck for 3 months; multiple joint
pain for 3 months and
On musculoskeletal system
examination,
there was scleroductyly with the
skin of both
hands being smooth, shiny, tight,
thick and
oedematous with
hyperpigmentation. No
telangiectasia was found. There
was no swelling, redness or
warmth in her joints. No muscle
wasting were present.
Provisional diagnosis
Limited Cutaneous
Systemic Sclerosis
(LCSS)
Differential
diagnosis
Investigations
Complete blood count
Hb% : 14 g/dl
ESR: 29 mm in 1st hr
WBC : 11800/cmm
Neutrophil : 59%
Lymphocyte: 35%
Monocyte : 03%
Eosinophil : 03%
Basophil : 0%
Platelet : 155000/cmm
Urine R/E
Pus cell: 4-5/HPF
Epithelial cells: 2-3/HPF
RBC, protein, suger: Nil
pH: Acidic
ECG: Suggestive of an old
anterior MI
RBS: 5 mmol/L
Serum Creatinine: 0.75mg/dl
Hormone Analysis
Serum T3: 1.50 ng/ml
Serum T4: 8.26 mcg/dl
Serum TSH: 1.94 mcIU/ml
Clinical Diagnosis
Thank you