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:

X RAYS

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