18 year old female patient with fever and vomiting


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. 


18 year old female patient came to OPD with cheif complaints of vomiting since 5 days

History of present illness:

Patient was apparently asymptomatic 2 months back, then she developed fever that was releived on taking paracetamol. After one week ,fever subsided  then she started having  multiple joints  pains in upper limb ( IP, MCP, Wrist, Elbow, Shoulder joint).It is pricking type of pain which disturb her daily activity. Pain is relieved on taking medication and developed again on stopping of medication . She also give complaints of oral ulcers. She had vomitings which was non bilious,non projectile , food as contents.

Past History:

No history of diabetes, hypertension,asthma, tuberculosis, Thyroid disorders.

Personal History:

Diet :mixed

Appetite :decreased since 3 months

Sleep :adequate

B&B: Regular

General Examination:

Patient is conscious,  coherent,  cooperative.

pallor is present.

No Icterus, cyanosis, clubbing,  generalised lymphadenopathy,  pedal edema. Rash is seen on the nose and cheeks.




Vitals:

Temp-afebrile

PR- 83bpm

RR-18/min

BP-110/60 mmhg

Systemic Examination:

CVS : S1 , S2 heard, no murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits

Investigations:



Coombs test:positive

ANA test : Positive

ds DNA test : Positive

Treatment:

1) Injection methylprednisolone 1gm IV Stat

2) Tablet paracetamol 650mg QID

3) Tablet pantop 40mg OD

4) Tablet zofer 4mg BD

5) IV fluids ‐ NS, RL, DNS ‐ 75ml/hr

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