FINAL PRACTICAL EXAM SHORT CASE- 47 YEAR OLD FEMALE WITH FEVER AND JOINT PAINS

General Medicine final practical exam- Short case

Reg no: 1701006068

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case :

CASE PRESENTATION

TIMELINE OF EVENTS:

A 47-year-old male has presented to the hospital on 02 June 2022 with the chief complaints of

• fever
• rash over the face

since 9 days

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic ten years ago then she developed joint pains in both knees and ankles, then both hands. There was swelling, and stiffness in the morning for around 15 minutes, with movement restrictions. The patient was treated at a private hospital and was diagnosed as RA POSITIVE and was prescribed diclofenac.

PAST HISTORY :

• Patient had a history of vision deterioration and began wearing spectacles at the age of 15 years, but the loss of eyesight was gradual, progressive, and painless, and he was declared legally blind. No relevant drug or trauma history .
• not a known case of hypertension , diabetes, asthma, epilepsy, TB.

PERSONAL HISTORY :

• married
• normal appetite
• takes mixed diet 
• bowel movements: regular
• micturition is normal
• no known allergies
• addictions: none

No similar complaints in the family.

GENERAL EXAMINATION:

Done after obtaining consent. The patient is conscious, incoherent, cooperative, well-nourished, and well -oriented to time, but not oriented to place and person.

• Pallor: present 

• No icterus, cyanosis, clubbing,lymphadenopathy, edema.

VITALS 

• Temperature - afebrile

• PULSE:86BPM

• BP:120/80mm hg
• RR:16cpm

LOCAL EXAMINATION:

erythematous rash is present on the cheek bilaterally. 10 days back there was itching which was gradually subsided. 

A swelling is seen on the left lower Limb on the lateral aspect with itching, local rise of temperature and redness.Pigmentation is seen. Associated with pain which is throbbing in nature non radiating type no aggrevating or relieving factors.

SYSTEMIC EXAMINATION:

1. CVS: 

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

apex beat normal at 5th ics medial to mcl

no additional palpable pulsations or murmurs

percussion: showed normal heart borders

auscultation: S1 S2 heard no murmurs or additional sounds

2. Respiratory system: 

inspection: normal chest shape bilaterally symmetrical, mediastinum central

no scars, Rr normal, no pulsations

palpation: Insp findings are confirmed 

percussion: normal resonant note present bilaterally 

auscultation: normal vesicular breath sounds heard

3. 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

4. CNS:

   Higher mental functions   

• conscious and cooperative coherent
• oriented to time, place and person.
• memory- recent and immediate memory intact

CRANIAL NERVE EXAMINATION 

2nd cranial nerve. Right.       Left

Visual acuity.        Counting fingers

Counting fingers postive 

Direct light reflex present.    Present

Indirect light reflex present.      Present

Perception of light.   Present.   Present

Remaining cranial nerves normal.

SENSORY :

touch, pressure, vibration, and proprioception are normal in all limbs

MOTOR-: normal tone and power 

reflexes:        RT         LT

BICEPS        ++         ++

TRICEPS     ++          ++

SUPINATOR  ++        ++

KNEE            ++         ++

                                                      

INVESTIGATIONS:

CBP

• Hemoglobin- 6 gm/dl 
• PCV- 21 % 
• TLC- 8200/ cumm 
• RBC- 2.5 million/cumm 
• Platelets- 1.32 lakhs/ml 

RA Factor- 34.4 IU/L 

Blood urea- 24 mg/dl (N)

Serum creatinine- 1.3 mg/dl (N)

Serum sodium- 136 mEq/L  (N)

Serum potassium- 3.7 mmol/l (N)

Serum chloride- 104 mEq/L (N)

LFT

Total bilirubin- 0.61 mg/dl  (N)

Direct bilirubin-  0.16 mg/dl (N)

SGPT- 48IU/L 

SGOT- 55IU/L 

ALP- 194 IU/L 

Albumin- 4 g/dl (N)

XRAY

DRUGS

PROVISIONAL DIAGNOSIS:

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

9HYDROCOTISONE cream 1%on face for 1week.