Final exam long case

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A 18 years old female patient presented to the opd with chief complaint of fever since 3months, joint pains since 2 months, vomitings 2months back for 1 week, headache 2months back. 

History of present illness

Patient was apparently asymptomatic 3months back then she developed fever, after the fever subsided she developed pain at the interphalangeal joints of left hand. Then later to the other joints of hands and legs which relieved on medication and relapse after stopping the medication

She had history of fever along with multiple joint pains. (small joints of hand ----> elbow---->shoulder joint).

Patient had a h/O migratory polyarthritis. 

H/O dragging type of pain in both lower limbs. 

H/O decreases appetite since 2months.h/o abdominal pain since 5days back. H/O vomitings since 2-3 days, non-bilious, non-projectile containing food particles. 

H/O of headache,burning sensation in the eyes. 

Past history

Not a known case of diabetes mellitus, hypertension, asthma, thyroid, TB. 

No history of any major surgeries in the past. 

Personal history

Appetite- decreased since 2months.

Diet - mixed

Regular bowel and bladder movements. 

Sleep adequate

Menstrual history

Menarche at the age of 13 years. 

Regular menstrual cycle. 

General examination

Patient is concious, coherent and co-operative. Well oriented to the time, place and person. 

Well nourished and moderate built. 

Pallor is present. 

No icterus, cyanosis, clubbing, generalised lymphadenopathy, pedal edema. 

Vitals

Temp: afebrile

Pulse rate: 83 bpm

Respiratory rate:18 cycles/min

Blood pressure: 110/60 mmhg. 

Spo2: 98%

GRBS:  120mg/ dl

Systemic examination

CVS:

S1, S2 heard

No murmurs heard. 

Respiratory system

Bilateral airway +

NVBS +

Per abdomen:

Soft, non tender

CNS:

Concious

No abnormality detected. 

Investigations:

ECG:

X- ray:

Ultra sound report:

Direct Coombs test:

Peripheral blood smear:

Complete blood picture:

Liver function test:

Rheumatoid factor:

Serum LDH:

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.