Final practical examination(short case)

 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome


18year old girl came with chief complaints of fever since 2months , joint pains since 2months, vomiting 2 months back for 1week, headache 2 months back.


HOPI :-
Patient was apparently asymptomatic 2months back ,then she developed fever following after fever subsides pt started having pain in the interphalangeal joints of left hand.Then later to other joints ,subsides with medication and relapse after stopping the medication.now she has h/o fever with multiple joints pains (small joints of hands ---->elbow---->shoulder). 

Patient had h/o migratory polyarthritis.

H/o dragging type of pain in the both lower limbs (Ankle joints & joints of foot are spared).

H/o decreased appetite since 2months .H/o pain abdomen (spasmodic type) since 5days back now subsides not associated with loose stools.
H/o vomitings since 2-3days ,non bilious,non projectile containing food particles.

H/o headache present , burning sensation in the eyes
PAST HISTORY

Not a known case of DM,HTN ASTHMA, THYROID,TB

PERSONAL HISTORY:-
Appetite -decreased since 2months

Diet:-mixed

Bowel & bladder-regular


O/E:

Pallor +

No Icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

Temp-afebrile

PR- 83bpm

RR-18/min

BP-110/60 mmhg

Spo2- 98%at RA

GRBS-120 mg/dl

CVS- S1 S2 +,No murmurs

RS- BAE+,nvbs +

P/A- soft, non tender 

CNS- NAD






INVESTIGATIONS;-

Chest X ray



X ray of hands










USG




ECG


Serum LDH
Direct coombs test

PROVISIONAL DIAGNOSIS:-
FEVER WITH POLYARTHRITIS (SECONDARY TO RA?  OR  SLE?) UNDER EVALUATION


TREATMENT;-

1)T. ULTRACET (325MG+37.5MG)  PO/QID

2)T.ZOFER (MD) 4MG PO/SOS

3)T.ZINCOVIT PO/BD 

4)T.LIMCEE PO/BD

5)T.PAN  40 MG PO/OD


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