Gm final practical short case:
February 2,
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18 year old girl presented to the opd with chief complaints of fever since 2months
joints pain since 2months ,
vomitings since 2months back ,
headache along with fever episodes since 2months,
pain in the abdomen since 5days back.
History of present illness:
Patient was apparently asymptomatic 2months back ,then she developed fever following after fever subsides pt started having pain in the small joints PIP,DIP,MCP subsides with medication and relapse after stopping the medication.now she has h/o fever a/w multiple joints pains (small joints of hands)
Patient had a history of migratory polyarthritis.
History of dragging type of pain in the both lower limbs (Ankle jnt& joints of foot are spared).
History of decreased appetite since 2months .H/o pain abdomen (spasmodic type) since 5days back now subsides not associated with loose stools.
History of vomitings since 2-3days ,non bilious,non projectile containing food particles.
History of headache and burning sensation in the eye
Past history:
No history of DM, HTN, ASTHMA, THYROID
Personal history:
Appetite -decreased since 2 months
Diet- mixed
Bowel and bladder movements -regular
Sleep- adequate
General examination:
Patient was conscious, coherent and cooperative well oriented to time, place and person.
Physical examination:
Pallor present
No icterus, cyanosis, clubbing, generalised lymphadenopathy.
Vitals:
Temperature - afebrile
PR-83bpm
RR-18bpm
BP-110/60 mm hg
Spo2-98%at RA
GRBS-120 mg/dl
Cvs-s1 and s2 are heard, no murmurs.
RS-BAE+, NVBS+
P/A-Soft, non tender
CNS-NAD
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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