MEDICINE FINAL PRACTICAL. (LONG CASE)
A 47 year old female with fever and joint pains...
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I have been given this case to solve in an attempt to understand the topic of "Patient clinical data analysis" to develop my competency i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
J.SRINATH REDDY
Roll no . 44
Hall ticket no : 1701006062
CASE SCENARIO
A ,47 year old female tailor by occupation resident of Nalgonda came to the OPD on 2/06/2022 with the chief complaints of
Fever since 3 months
Facial rash since 10 days
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 10 years ago then she developed joint pains first in the both knees and ankles followed by both the hands. There was swelling associated with pain morning stiffness for about 15mins associated with limitation of movements. For this patient was treated in private hospital and was tested RA POSITIVE and was on diclofenac, remained asymptomatic for 8 months.
Last year at around month of August patient took vaccination for covid - one dose following which she has developed post vaccination joint pains.
In the month of November patient consulted orthopedic and was given medication and thus relieved from symptoms. Later 3 months back then she developed fever which was Insidious in onset Intermittent on and off not associated with chills and rigor. Relieved on medication . She went to the private hospital but the fever was recurrent associated with abdominal pain came here on 02/06/2022.
1 month back patient had an episode of loss of consciousness associated with sweating after taking metformin tablet prescribed by local RMP
Patient also had facial rash over the face which increased on exposure to sun. It was a diffuse erythematous lesion and hyperpigmented papules were noted over the bilateral cheek sparing nasolabial folds,following intake of unknown medication for abdominal pain.
PAST HISTORY
Patient had an history of gradual painless loss of vision since 2011and was certified as blind
Not a known case of diabetes ,asthma ,epilepsy, thyroid ,tuberculosis and coronary artery disease.
No similar complaints in the family
PERSONAL HISTORY
Diet: Mixed .
APPETITE: Decreased .
SLEEP: Disturbed.
BOWEL AND BLADDER MOVEMENTS : Regular .
ADDICTIONS : No addictions.
GENERAL EXAMINATION
Patient is conscious ,coherent co operative well oriented to time place and person ,moderately built and moderately nourished and is examined with informed consent.
Pallor: present
No icterus, cyanosis, clubbing, lymphadenopathy, edema.
VITALS
PULSE :86BPM
BP:120/80mm hg
RR:16cpm
SPO2:98%at room air
LOCAL EXAMINATION
There is swelling in the left lower Limb on the lateral aspect with itching, local rise of temperature and redness. Pigmentation is seen and swelling was associated with pain which is throbbing in nature non radiating type no aggravating or reliving factors.
Dorsalis pedis artery is felt.
Erythematous rash is present on the cheek bilaterally. It is not associated with itching now. 10 days back there was itching which was gradually subsided.
SYSTEMIC EXAMINATION
CVS
ON INSPECTION:SHAPE OF THE CHEST IS NORMAL
no visible neck veins
No rise in JVP
No visible pulsation scars.
PALPATION
ALL inspectory findings are confirmed .
Cardiac impulse felt at 5ty intercostal space 1cm medial to the mid clavicular line.
Percussion shows normal heart borders
Auscultation : S1 ,S2 heard no murmurs.
CNS
Normal tone and power.
SENSORY SYSTEM: Touch vibration proprioception normal.
MOTOR SYSTEM: Normal tone and power.
REFLEXES: Right Left
BICEPS. 2+ 2+
TRICEPS. 2+ 2+
SUPINATOR. 2+ 2+
KNEE. 2+ 2+
GIT:
inspection- normal scaphoid abdomen with no pulsations and scars
palpation - Inspectory findings are confirmed
no Organomegaly, non tender and soft
percussion- normal resonant note present, liver border normal
auscultation-normal abdominal sounds heard, no bruit present
RESPIRATORY
Shape of chest is elliptical,
B/L symmetrical chest,
Trachea in central position,
Expansion of chest- left normal
Right _ decreased
PALPATION
All inspectory findings are confirmed.
No tenderness, No local rise of temperature.
trachea is deviated to the right.
Tactile vocal fremitus: decreased on right side ISA, Infra SA, AA, IAA.
PERCUSSION: Dull note present in right side ISA, Infra SA, AA, IAA.
AUSCULTATION: B/L air entry present, vesicular breath sounds heard,
Decreased intensity of breath sounds in right SSA,IAA,
INVESTIGATIONS
SECONDARY SJOGRENS SYNDROME
LEFT LOWER LIMB CELLULITIS
TREATMENT:
1.INJ PIPTAZ 4.5 gm IV/ TID.
2.INJ METROGEL100 ML IV/TID
3.INJ NEOMOL1GM/IV/SOS
4.TAB CHYMORAL FORATE PO/TID
5.TAB PAN 40 MG PO/ OD.
6.TAB TECZINE10 MG PO/OD
7.TAB OROFERPO/OD.
8.TAB HIFENAC-P PO/OD
9.HYDROCOTISONE cream 1%on face for 1week.
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