General Medicine Final Practical




General Medicine Final Practical Long Case




This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's 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. This e-log book also reflects my patient centered online learning portfolio and your valuable inputs on comment box is welcome 


18year old girl came with chief complaints of fever since 2months back 
*joints pain since 2months back

*vomitings since 2months back 

*headache along with fever episodes since 2months

 * pain in abdomen (diffuse)since 5days back


History of present Illness 

Patient was apparently asymptomatic 2months back then she developed fever following after fever subsided patient started having pain in the small joints PIP,DIP,MCP which subsided with medication and has a relapse after stopping the medication Now  she has fever associated with multiple joints pains (small joints of hands ---->elbow---->shoulder). 

Patient has history of migratory polyarthritis.

History of dragging type of pain in the both lower limbs (Ankle joint and joints of foot are spared).

History of decreased appetite since 2months .History of pain in abdomen (spasmodic type) since 5days back now it subsided ,not associated with loose stools.
History of vomitings since 2-3days ,non bilious,non projectile containing food particles.

History of Head ache ,burning sensation in the eyes

Past History 

No history of DM,HTN ASTHMA, THYROID,TB

Personal History 

Diet: mixed

Appetite -decreased since 2months

Sleep: Adequate 

Bowel & bladder moments -regular

No addictions

Menstrual History 

Menarche at the age of 13 yrs
Regular menstrual cycle


Family History 

 No significant family history 

General Examination 

Patient is conscious, coherent, cooperative.

No pallor, icterus, clubbing, lymphadenopathy, edema

Vitals

Temperature -Afebrile

PR-83bpm

RR-18/min

BP-110/60

SpO2-98% at RA

GRBS-120 mg/dl

Systemic Examination 

CVS-S1 S2 +, No murmurs

RS- BAE+ nvbs+

P/A soft, non tender

CNS - NAD










Chest X-ray 




X ray of hand


X ray of pelvis


USG




ECG



TPR



Complete Blood Picture 


Liver function Test


PeripheralSmear



Rheumatoid factor 




LDH  



Direct Coombs Test




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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