DR.W.A.P.S.R.WEERARATHNA

REGISTRAR- WARD 10/02

Mr. A is a 58 years teacher from mannar who is a hypertensive presented with progressive discoloration of medial three fingers over last 3 months duration.

It was associated with intense pain , where he claimed that pain was more pronounced in the eairly hours of the day.

He also had tingling & numbness, specially when he immerses his affected hand in to cold water.

He had no similar changes in the right hand, in the feet or any other extremity in the body.

Pain wasn’t responded to simple analgesics & he used to elevate the hand during attacks where he had some relief.

He denies associated constitutional symptomps like fever, malaise, LOA,LOW & genaralized illhealth.

He had no H/O claudication in the left hand or acute ischaemic type of pain in the limbs.

There is no H/O TIA or a stroke in the past.

He had no fractures in the left hand in the past or any painful restricted neck movements.

He denies a H/O small or large joint arthritis, associated body rashes including petichiae or ecchymosis.

No oral ulcers,photosensitivity or hair loss.

No H/O myalgia,girdle type or pain.

No complaints of nasal stuffiness,mucusdischarge,epistaxis or hoarseness of voice.

He had no H/O chronic cough,wheezing,allegic type of rhinitis in the past.

He denies haematuria & or associated haemoptysis.

There is no ‘B’ symptoms, bone pains, H/O chronic back pain, pathological fractures in the past & he denies any haemorrhagic diathesis.

No H/O abdominal pain specially in the LUQ , H/O headache,visual deterioration, aquagenic pruritus.

No passage of dark urine, pale stools,H/O any BT in the recent past.

No H/O radicular type of pain, sensory disturbances in the limbs.

With this history he got admitted to a LH where he was subjected to an array of several invasive/ noninvasive investigations including imaging & ultrasonography.

He was then started on oral medication where there was no much response.

He was transferred to THJ for further evaluation & management.

PMH: No H/O DM,IHD,BA.

PSH: not significant

DH: Not on any regular medication.

AH: No allergies.

Dietary Hx: Nonvegetarian diet.

FH: No significant illnesses run among family members.

SH: Ex-smoker,social drinker,married & has 3 children. Wife is a HW, difficult to attend ADL & also difficulties encountered during teaching in the school as a teacher. knowledge reguardinghis illness is poor.

Not pale/plethoric

Not icteric

Afebrile

BMI- 27 Kg/m2

No rashes-palpable purpura/petichiae/photosensitivity

No B/L pitting AE

No clubbing

B/L Phalen’s sign/Tinnel’ sign negative

No F/O a Rheumatoid hand/rheumatoid nodules

Adson’s sign -negative

No scleritis/episcleritis

Neck –no palpable cervical ribs, ROM- normal

Pulse oximetry-spO2: 100% both hands

CVS:pulse B/L radial pulse+/no R-R/R-F delay

Good volume & normai in character

BP-140/90 mmHg,PR-88/min,regular

No cardiomegaly,no detectable cardiac murmurs

AS:No organomegaly

RS:No added sounds,vesicular breath sunds+

CNS: No focal neurological deficites,Fundoscopy-normal

Mr.A a 54 year old teacher with past H/O HTN C/O progressive discoloration of terminal phalanges of medial 3 fingers of left hand over 3 months duration.O/E there are bluish discoloration of the affected parts with no other similar leasions elsewhere. Systemic exam revealed normal findings.

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2014/08/08 2014/08/12 2014/08/15

Hb 11.3 12.4 12.2

Hct 43 39 40

RBC

WBC 8000 8300 8240

PLT 607000 678000 795000

RBC: NCNC RBC

WBC:withi normal limits & Neutrophilpredominance

PLT: Throbocytosis with clumps

COMMENT: Thrombocytosis.? Cause

Sugest-exclude reactive cause of throbocytosis,JAK-2 mutation from peripheral blood,consider Aspirin if there is no C/I,USS-Abd

ESR:0511mm/hr

CRP:0810 3.4mg/dl

BU: 42mg/dl

S.Cr: 0.9mg/d/l

SE: S.Na+ 137 mmol/l

S.K+ 4.5 mmol/l

98 mg/dl

NORMAL

NORMAL 2D ECHOCARDIOGRAME

TC: 187 mg/dl

TG: 152 mg/dl

HDL-C: 41 mg/dl

LDL-C: 116 mg/dl

VLDL-C: 30 mg/dl

TC/HDL-C: 4.6

NORMAL,NO CARDIOMEGALY

APP-clear

PC-Nill

RBC-Nill

EC-Few

CAST-Nill

CRYSTALS-Nill

AST: 73 U/L

ALT: 5I U/L

ALP: 148 U/L

T.BIL: 0.4 mg/dl

T.PRO: 66.9 mg/dl

Alb: 37 mg/dl

Glb: 29 mg/dl

HBs Ag- NEGATIVE

HCV Ab-NEGATIVE

Liver/portal veins/pancrease –NORMAL

B/Lkinneys/bladder-NORMAL

IMPRESSION-NORMAL USS OF THE ABDOMEN

Subclavian,axillary,radial & ulnar arteries shows normal diameter/normal flow patter/triphasic flow pattern noted/no significant narrowing noted.

RF: NEGATIVE

ANA: NEGATIVE

C-ANCA: NEGATIVE

P-ANCA: POSITIVE

JAK-2 mutation: NEGATIVE