50 year old female with cutaneous vasculitis??

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Chief complaints: 

1) Ulcers over the body 

2) swelling over the gluteal region

3) Difficulty swallowing

4) Nausea sensation

5) Generalized weakness

50 year old female , House wife by occupation mother of 3 children (1son and 2 daughters ).

 Story of her son : Her son died at his 15 years of his age( when asked she said he had polio, at birth he didn't cried, from 4 years of age, he developed seizures , on /off.One day, every one went outside , when she came back, found her son in unconscious state, with froth from his nose and when taken to hospital, found dead.

20 years back, patient had bleeding from her skin of left ankle joint ,but she is unaware of the bleeding till her neighbours told she is bleeding from the skin.and went to the hospital and consulted dermatologist and used medication and subsided.

19 years ago, The same thing happened but this time from the right ankle joint.

She is a housewife, used to daily house hold activities and cooking for her children and husband. She was normal till 2 months back, then she started developing small hard swellings on the gluteal region and ulcers started developing initially over the both popliteal region ,then gluteal region and thigh region , and left nipple region ( first there is development of one ulcer, followed by next ).and these are painful, ,but not associated with any discharge,along with the difficulty swallowing the food for solids , Associated with burning sensation and she used to eat food with milk/curd because of difficulty swallowing.after 15 days she developed breathing difficulty on exertion and cough ( dry) ,which gradually aggravated to breathing difficulty at rest ,taken to hospital,where they said it was pneumonia and treated for 6 days and at the same time , diagnosed with hypothyroidism and started on thyronorm 25mcg aand got discharged. Then ulcers started forming on the both palms, including both hands and elbow region.

The ulcers were so painful that she could not,she feel difficulty to mix the food, and also getting from the bed.and she was brought here for further evaluation and admitted under Dermatology.

GENERAL EXAMINATION:

No pallor ,icterus,clubbing,cyanosis,lymphadenopathy.

Pedal edema.

SYSTEMIC EXAMINATION:

BP: 120/80

PR;80BPM

CVS:S1S2+

RS; BAE+

P/A: SOFT,NON TENDER

pigmentation over the right nipple area .

.       Right elbow

while palpating right gluteal region ,i could plapate approx 1cm hard swellings.

They are not visible outside

ulcers around anal and gluteal region

.   Left  arm.

left forearm region

To Summarise: 

50 year old female with painful ulcers  over the body with difficulty swallowing, swellings over the gluteal region with hypothyroidism with glomerulonephritis with mild LVH and positive Rheumatoid factor.