1. Salman SaleemFCPS-II trainee

2. Name: aaaAge: 22 yearsGender: femaleMarital Status: UnmarriedResident of lahoreDate of presentation: 22nd May 2014 3. Presented with chief complaint ofLeft upper limb pain-----------1month 4. My patient had pain in left upper arm, mostsever in left forearm and hand which wasAching in nature, present most of the timeand aggravated by doing any kind of work.There was associated numbness andcoldness of the left hand.There is no history of any color changeson exposure to cold. There is no H/O skinrash or fever 5. There is H/O generalized body aches andpains, sometimes left shoulder pains but nosystemic joint pains, stiffness, redness orswelling. There is no HO lower limb pain orclaudication. No Chest pain or SOB No HO vertigo, dizziness, blackouts orheadache No HO cough sputum, hemoptysis, burningmicturtion, hematuria, pyuria No GIT disturbance Normal periods. 6. She had Hx of fever 07 months back. The fever continued for 01 month. It was mostly lowgrade, intermittent. fever was associated body achesand join pains involving both small and large joints.There was no joint swelling or stiffness There was also dry cough and exercise intolerance.There was no HO hematuria or burning. No GITsymptoms. No hx Skin rash She remained under treatment from various physiciansand got worked up to find out the cause of fever but noconclusive diagnosis could be made. The fever finallysubsided after 01 month 7. Hb: 11.2 TLC: 6.2 PLT: 335000 MCV: 86 Urea: 17 Creatinine: 0.5 Uric acid: 3.1 Bil: 0.4 SGPT: 23 Alk Po: 81 Calcium: 10.0 25 OH vit D3: 37.32 Total protein: 7.8 Alb: 4.6 Globulin: 3.2 ESR: 70 CRP: < 6 ANA: -ve RA Factor: -ve Anti CCP: -ve Transthoracic Echo:Normal Valves normal systolicand diastolic dimensionsand EF of 55% 8. Family history: no history IHD,DM ordyslipidemia any similar illness in familyPersonal Hx: She is staff nurse byprofessionThere is no HO, smoking, addiction or drugdependanceMenstrual History: noramal 9. Young female of average height and built looksanxious BP: 110/70 in rt arm and was not recordable in leftarm PULSE: 90 b/min ABSENT LEFT RADIAL. Left brachial but ulnar arterywas very feeble. There was no change in pulse withchange of position of left UL or neck All other pulses were normal. no radiofemoral delay R/rate: 18/min Temp: 98.6F 10. There was no clubbing, cyanosis or edema Chest: Normal vesicular breathingAbd: Soft non tender no palpablevisceromegaly CVS: S1 and S2 audible with no murmurCNS: Normal examination 11. 1)Vasculitis: Large vessel:Takayasus arteritis , Giant cell arteritis,2)Atherosclerosis3)Buergers disease4)Thoracic outlet syndrome5)Coarctation of Aorta(Medium vessel vasulitis: Polyarterititis nodosa,kawasakis diseaseSmall vessel: wegners granulomatosis , rheumatoid arthritis,)were also in differentials 12. Giant cell arteritis occurs in elderly with headacheand jaw claudication Thoracic outlet syndrome: its pain is aggravated with movement in vascular typethoracic outlet syndrom Coarctation of Aorta: Pt has no radiofemoral delay and hypertention Athersclerosis: donot involve subclavian artery as individual . No family historyof dyslipidemia Buergers disease ocuurs in middle aged smoker male and effects lower limb PAN associated with abdominal pain, rashes, hematuria and peripheralneuropathy Kawasaki disease occurs in childhood pts have eye symptoms,lymphadenopathy and cutaneous lesions Wegners Granulomatosis: is associted with upper respiratory symptoms andhemoptysis Rheumatoid arthritis: ho morning stiffness and multi organ involvement 13. CBC,ESR,ANA, RA factor, ENA, C-ANCA,P-ANCA,LFTS,RFTs,Lipid porfileECGCXRArterail DopplerCT Peripheral Angiogram was planned 14. Hb: 10.2 Plt: 453000 Tlc: 7800 Mcv: 80.6 ESR: 58 CRP: