A classical case of a 29 year-old woman with rash over the face, neck and upper trunk with bilateral upper and lower limb swelling + weakness

A 29 year old woman hailing for Choutuppal came to the medicine OPD with the chief complaints of rash over the face, neck and upper trunk with dark colored skin lesions over the knuckles since 10 months.

She also complained of joint pains in bilateral upper and lower limbs especially in the knees, elbows, wrists and other small joints which is associated with morning stiffness since 10 months. She complains of swelling in bilateral hands, legs and generalized weakness since 10 months.  She also complains of an inability to comb her hair and inability to sit down in the floor. 

She has a history of photosensitivity (increased itching after sun exposure). She had oral and genital ulcers on and off.

She also has a history of hair loss since 10 months. History of white discharge since 10 months. 

Past history and Family history : 

No other Co-morbidities present. None of her family members suffer with the same problem. 

Marital history :

She has been married for 14 years. She has tried to conceive but has no children. She denies having any abortions.

Menstrual history :

She bleeds for 3 days every 30 days. Has regular menstrual cycles and uses 2 pads/day.

Vitals :

Temp : Afebrile 

PR : 76 BPM

BP : 120/70 mm of Hg

RR : 17 CPM

On general examination :

She has mild Pallor and Pedal edema. 

No icterus, cyanosis, clubbing, kilonychia, lymphadenopathy.

On local examination :

Diffuse, mottled, Erythema tours, hyperpigmentation noted on cheeks (Malad rash) , nose (bridge) involving the nasolabial folds, ears 

Neck, extending onto upper chest and back forming a 'V' shape on the anterior chest. 

Few hyperpigmented macules noted on mid and lower back. (V sign /Shawl sign). 

Single erythematous macule noted over the right loin (Holster sign).

 Pigmentation of bilateral knuckles noted (Gottron's papules).

Mechanic's hands :

On examination of the external genitalia :

White discharge is noted over the labia majora.

Provisional diagnosis :

? DERMATOMYOSITIS

? SLE

WITH VAGINAL CANDIDIASIS