18 year old female with FEVER & POLYARTHRITIS

Medical case disscussion 


14-2-22


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Name : Mounika 7th sem 

Roll no : 46

I have been given this case to solve an attempt to understand the topic of "patient clinical analysis data " to develop my competency in reading and comprehending clinical data including clinical history,clinical findings, investigations and come up with a diagnosis and treatment plan

18 year old female with FEVER and POLYARTHRITIS. 

A 18 year old female presented to the OPD with cheif complaints of FEVER  and vomitings since yesterday, fever was on and off since   3 months and there was pain in the small joints PIP, DIP, MCP etc , vomitings  3 months back for 1 week, headache along with fever episodes since 3 months  , pain in abdomen 10 days back which lasted for 20 days

●HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 3 months back then she developed fever, following which fever was subsided and the patient started having pain in the small joints PIPI,DIP,MCP joints,subsided with medication and relapsed after stopping medication. Now she has fever with multiple joint pains ( small joints of hands,elbow,shoulder,) .Patient had history of migratory polyarthritis ,history of dragging type of pain in the both lower limbs. ( Ankles and joints of foot are spared).

History  of  decreased appetite since 3 months  ,history of pain abdomen (spasmodic type) 10 days back for which she took medications

History of vomiting, non bilious, non projectile containing food particles.

History of headache with burning sensation in the eyes.

She stopped taking medicines since last two days because every time she takes medicines ,she is having vomiting episodes and she was vomiting everything she eats since yesterday morning

●PAST HISTORY 

No similar complaints in the past 

●MEDICAL HISTORY 

No significant medical history 

●FAMILY HISTORY 

No significant family history 

●PERSONAL HISTORY 

Mixes diet

REDUCED APPETITE 

Regular bowel and bladder movements

No addictions or allergies 

●GENERAL EXAMINATION 

The patient was examined in a well lit room after obtaining consent.

Patient was conscious coherent and cooperative and she was moderately built and moderately nourished. 

Pallor present 

Icterus-absent 

Cyanosis-absent 

Clubbing-absent 

Lymphadenopathy-absent

Pedal edema-absent 

And she also developed rash on her face and hands

●VITALS 

Temperature-afebrile 

Pulse rate-82 beats per minute 

Respiratory rate-18 breaths per minute 

Blood pressure-100/70 mm hg

SpO2-98 percent at room air

●SYSTEMIC EXAMINATION 

Cardiovascular system-S1 and S2 heard ,no murmurs heard 

Respiratory system - vesicular breath sounds are normal

Abdomen-no palpable mass,no organomegaly.

Central nervous system:

   Patient was conscious, coherent and cooperative 

   Speech was normal 

    No slurred speech 

    No Meningeal irritation signs.

No abnormality detected. 

REFLEXES 

 Gait is normal

             ●  INVESTIGATIONS 

○Usg report 

○LAB INVESTIGATIONS 

Serology 

○HBsAg,HIV1/2 all are negative 

○Haemogram 

Erythromycin sedimentation rate is 80mmper 1st one hour

C reactive protein is negative. 

○Renal function tests 

○Liver function tests 

○Complete urine examination 

○Random Blood sugar is 125mg/dl

○Rheumatoid factor is negative 

○ECG:

●X RAYS

●PROVISIONAL DIAGNOSIS 

Fever with polyarthritis,  

Fever since yesterday because she stopped taking medicines

●Treatment:

1.TAB ULTRACET(325mg+37.5mg)

2.TAB ZOFER(MD)4 mg PO/SOS

3.TAB ZINCOVIT PO /BD

4.TAB LIMC66 PO/BD

5.PAN 40 mg PO/OD