GENERAL MEDICINE CASE

 B.VAISHNAVI

5th SEMESTER

ROLL NO. 22

This is an online E log platform to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. I have been given this case in order to solve in an attempt to understand the topic of patient's clinical data analysis to develop my competency in reading and comprehending clinical data and come up with a diagnosis and treatment plan.

A 35 year old female came to the opd with chief complaints of fever, swelling and pain around the joints since 20 days. 

HISTORY OF PRESENT ILLNESS:

Patient was apparently asymptomatic 12 years back, then she complained of swelling of the uterus, abdominal pain and abnormal uterine bleeding, not subsided even on medication so, hysterectomy was done. Then, 3 years back, she developed fever, bilateral swelling and pain around the joints-(unable to make a fist)( ankle joint, elbow, wrist, small joints in fingers) for 3-4 months in the past 2 years

Patient complained of fever(night and afternoon) associated with cough, swelling and pain in the joints since 20 days, she had history of  weight loss, weakness. 

No h/o morning stiffness

HISTORY OF PAST ILLNESS:

k/c/o epilepsy (one episode when she was 6 months old) 

She was on anti epileptic drugs from 6 months to 3 years continuously and then stopped. 

not a k/c/o DM, HTN, ASTHMA, CAD

Hysterectomy is done 12 years back due to swelling of the uterus associated with abdominal pain( not subsided even on medication) 

PERSONAL HISTORY:

Appetite- lost

Sleep- disturbed

Mixed diet

Bowel and bladder movements-regular

No allergies

FAMILY HISTORY:

Not significant

GENERAL EXAMINATION

patient is conscious, coherent, cooperative

Absence of pallor, icterus, cyanosis, lymphadenopathy, edema

VITALS

Temperature: Afebrile

Pulse rate:74/min

Respiratory rate :16/min

Spo2:95%at room air

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:

S1, S2 heard

Thrills absent

No murmurs

RESPIRATORY SYSTEM:

Normal vesicular breath sounds 

Trachea is in central position

No dyspnoea

No wheeze

ABDOMEN 

shape of abdomen- scaphoid

No tenderness

No palpable mass

Normal hernial orifices

No free fluid

No bruits

Liver and spleen are not palpable

Bowel sounds heard

CENTRAL NERVOUS SYSTEM

Patient is conscious

Speech-normal

No signs of meningeal irritation

Motor and sensory system is intact

PROVISIONAL DIAGNOSIS:

ACUTE FEBRILE ILLNESS WITH REACTIVE ARTHRITIS




INVESTIGATIONS:














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