Final exam long case

 This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent

Here we discuss our individual patient 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.

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.





Comments

Post a Comment

Popular posts from this blog

A 35 years old male patient with hepatic encephalopathy

Image
 This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent Here we discuss our individual patient 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. A 35 years old male patient present to the opd with chief complains of altered sensorium,yellow discoloration of sclera, pedal edema since 1 week.  History of present illness Patient was apparently asymptomatic 6 years back. Then he developed yellowish discoloration of sclera in 2014 with altered sensorium so he took treatment in hospital in Hyderabad.  Where he was diagnosed as the chronic liver disease. From then he was on medication.  Patient has habit of alcohol, so he was adviced not to consume alcohol.  He stopped the medication and continued drinking alcohol.  He had fever from 4 days which is subsided on medication.  Histo
Read more

Case 2

Image
 This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent Here we discuss our individual patient 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.  A 52 years old male patient presented to the opd with chief complaint of swelling of the body parts with fever and vomitings. HISTORY OF PRESENT ILLNESS Patient was apparently asymptomatic 4 years ago, then developed swelling of body parts fever and vomitings.  4 years ago patient had recurrent fever for which he visited the hospital, where he diagnosed as acute kidney injury. Later presented to KIMS for further evaluation.  The patient had decreased urine output, swelling in the abdomen and pedal edema. PAST HISTORY Patient is a K/C/O hypothyroidism since 10 years. Patient had a known history of NSAID's use 7 years ago. Pati
Read more

56 year old male patient with dengue fever

Image
 This is online elog book to discuss for patients deidentified health data shared after taking her/guardians signed informed consent Here we discuss our individual patient 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. A 56 year old male patient presented to the opd with fever since 10 days.  History of present illness Patient was apparently asymptomatic 10 days back. Then he developed fever which was continues , decreasing after taking anti pyretics and again increasing.  Patient went to local hospital , then also fever did not subside so came to the KIMS.  Fever is insidious in onset, no diurnal variation.  Fever is not associated with chills or headache.  History of decreased urine output since 3days. Past history There is no history of diabetes, hypertension, TB, epilepsy There is no history of any major surgeries.  Personal history Patient
Read more