General medicine case discussion
B.Varshitha
5th semester
Roll no.21
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A 38 7year old female patient came to the hospital with cheif complaints of fever with cough and swelling and pain in joints since 20days
History of present illness
The patient was apparently asymptomatic 12years back she had heavy menstural bleeding and swelling of uterus which was not subsided on medication and Hysterectomy was done and 3years back then she developed swelling and pain in joints started in both ankle joints and then included both elbow, wrist and small joints of hands associated with on and off fever for 3-4months (June to September) then fever and pains were subsided for the next 8-9months.
1 year back she again developed on and off fever associated with swelling and pain in joints for 3- 4months ( june to September) which was subsided.
20 days back she developed fever which is intermittent associated with swelling and pain in joints for which she went to the local hospital and treated but symptoms were not relieved so came here
H/O weakness is present
H/O weight loss is present
No H/O morning stiffness is present
No H/O burning micturation and decreased urine output.
History of past illness
K/C/O epilepsy
12years back she had heavy menstural bleeding and swelling of uterus which was not subsided on medication and Hysterectomy was done
N/K/C/O HTN, Diabetes, asthma,CAD
Family history
No history of HTN, Diabetes, epilepsy, asthma,CAD
Personal history
• Diet : mixed
• Appetite: lost
• Sleep : distributed
• Bowel habits: normal
• Bladder habits : normal
• No Addictions
Physical examination
General examination
• No pallor
• No icterus
• No cyanosis
• No lymphadenopathy
• No clubbing of fingers
• Moderately built and moderately nourished.
Vitals
Temperature: Afebrile
Pulse rate: 74/min
BP: 110/80
RR:16/min
Spo2:95% at room air
SYSTEMIC EXAMINATION
CVS
S1,S2 Heard
No murmurs
RESPIRATORY SYSTEM
No Dyspnea
No wheezes
Trachea-Central
Breath sounds-vesicular
ABDOMEN
No Distended abdomen
No tenderness
No palpable mass
No free fluid
No briuts
No palpable spleen and liver
CNS
Conscious
Coherent
Cooperative
Speech-normal
No neck stiffness
Sensory system- Normal
Motor system- normal
Provisional diagnosis: Acute febrile illness with reactive arthritis
Investigations
ECG
X ray
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