18 year old female with FEVER AND POLYARTHRITIS

February 2,2022

18 year old female with FEVER and POLYARTHRITIS. 

A 18 year old female presented to the OPD with cheif complaints of FEVER  2 months back  , after which fever  was subsided, and there was pain in the small joints PIP, DIP, MCP etc , vomitings  2 months back for 1 week, headache along with fever episodes since 2 months  , pain in abdomen since 20 days

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 2 months back then she developed fever, following which fever was subsided and the patient started having pain in the small joints PIPI,DIP,MCP joints,subsided with medication and relapsed after stopping medication. Now she has fever with multiple joint pains ( small joints of hands,elbow,shoulder,) .Patient had history of migratory polyarthritis ,history of dragging type of pain in the both lower limbs. ( Ankles and joints of foot are spared).

History  of  decreased appetite since 2 months  ,history of pain abdomen (spasmodic type) since yesterday. 

History of vomiting, non bilious, non projectile containing food particles.

History of headache with burning sensation in the eyes.

PAST HISTORY 
No similar complaints in the past 

MEDICAL HISTORY 
No significant medical history 

FAMILY HISTORY 
No significant family history 

PERSONAL HISTORY 
Mixes diet
REDUCED APPETITE 
Regular bowel and bladder movements
No addictions or allergies 

GENERAL EXAMINATION 
Pallor present 
Icterus-absent 
Cyanosis-absent 
Clubbing-absent 
Lymphadenopathy-absent
Pedal edema-absent 

VITALS 
Temperature-afebrile 
Pulse rate-82 beats per minute 
Respiratory rate-18 breaths per minute 
Blood pressure-100/70 mm hg
SpO2-98 percent at room air

SYSTEMIC EXAMINATION 
Cardiovascular system-S1 and S2 heard ,no murmurs heard 
Respiratory system - vesicular breath sounds are normal
Abdomen-no palpable mass,no organomegaly.
Central nervous system:
   Patient was conscious, coherent and cooperative 
   Speech was normal 
    No slurred speech 
    No Meningeal irritation signs.

No abnormality detected. 

REFLEXES 
 Gait is normal

               INVESTIGATIONS 
Usg report 

LAB INVESTIGATIONS 

Serology 
HBsAg,HIV1/2 all are negative 


Haemogram 

Erythromycin sedimentation rate is 80mmper 1st one hour
C reactive protein is negative. 

Renal function tests 


Liver function tests 
Complete urine examination 

Random Blood sugar is 125mg/dl

Rheumatoid factor is negative 

ECG:
PROVISIONAL DIAGNOSIS 
Fever with polyarthritis 

Treatment:
1.TAB ULTRACGT(325mg+37.5mg)
2.TAB ZOFER(MD)4 mg PO/SOS
3.TAB ZINCOVIT PO /BD
4.TAB LIMC66 PO/BD
5.PAN 40 mg PO/OD








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