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