13 YRS OLD BOY WITH ACUTE FEBRILE ILLNESS

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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 in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan. is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input

A 13 years old male student who resides at hostel came to opd on 2/7/24 with complains of

     - redness of eyes since 5 days (L>R).

     - fever since 4 days.

     - burning micturition since 4 days.

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 5 days ago then he developed redness of eyes which is sudden in onset, followed by fever which is of high grade , insidious in onset and gradually progressive, associated with burning micturition.

history of swelling over both cheek areas (L>R) since 4days .

history of yellowish discoloration of eyes since 3days.

history of pain and difficulty in flexing the left knee since 2days associated with progressive swelling .

PAST HISTORY:

no history of any recent travel.

no history of similar complaints in the past.

PERSONAL HISTORY:

diet: mixed diet      appetite: lost

bowel : regular        micturation: burning micturition since 4days.

 no addictions.

FAMILY HISTORY:

not significantsignificant. 

GENERAL EXAMINATION: patient is conscious ,coherent , cooperative .

icterus present 

no pallor, cyanosis, clubbing, lymphedenopathy, edema 

VITALS: 

 temp: 101F

 bp: 110\70mmhg

 pulse rate: 100bpm

 respiratory rate: 18cpm

SYSTEMIC EXAMINATION: 

CVS: s1 s2 heard no added murmurs 

RS:  BAE+ ,NVBS heard 

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

CNS: no focal neurological deficit .

PROVISIONAL DIAGNOSIS:

acute febrile illness ?mumps ? reactive arthritis ? septic arthritis ?leptospirosis 

INVESTIGATIONS:

2/7/24:

HEMOGRAM

HB: 11.2%

TLC: 13,400 cells/cumm

N/L/E/M: 68/20/02/10

PCV: 36.2

MCV: 79.2

MCH: 27.4

MCHC: 34.4

RBC: 4.5 millions/cumm

PLATELETS: 4 lkhs/cumm

CUE

COLOR: pale yellow

APPEARANCE: clear

SP.GRAV: 1.010

ALBUMIN: nil

SUGARS: nil

BILE SALTS AND PIGMENTS: nil

PUS CELLS: 2-3

EPITHELIAL CELLS: 2-3

RBC: nil

others: nil

RFT

SR UREA: 19

SR CREATININE : 0.6

SODIUM: 128

POTASSIUM: 5.9

CHLORIDE: 101

CALCIUM: 1.19

ESR: 130

PT: 16secs

INR: 1.11

BT: 2min 30secs

CT: 5min 00secs

APTT: 32sec

M.P. STRIP TEST: negative

DENGUE

NS1 ANTIGEN: negative

IgM: negative

IgG: negative

3/7/24

HEMOGRAM

HB: 10.9%

TLC: 11,000 cells/cumm

N/L/E/M: 71/19/01/9

PCV: 32.2

MCV: 79.5

MCH: 27.0

MCHC: 34.0

RBC: 4.05 millions/cumm

PLATELETS: 3.3 lkhs/cumm

LFT

TB:0.7mg/dl

DB:0.18mg/dl

AST:12 IU/L

ALT:13 IU/L

ALP:87 IU/L

TP: 7.1gm/dl

ALBUMIN: 3.27gm/dl

A/G RATIO: 0.85

SERUM ELECTROLYTES:

SODIUM: 131mmol/l

POTASSIUM: 3.8mmol/l

CHLORIDE: 105mmol/l

CALCIUM: 1.19mmol/l

CRP: positive(2.4mg/dl)

ASO TITRES: 311.7 IU/ML

LEPTOSPIRA ANTIBODY IgG: 0.22 OD UNITS.

USG OF LEFT KNEE (2/7/24)

E/O mild joinnt effusion noted in suprapatellar fossa extending to medial and lateral aspect with surrounding inflammatory changes

E/O inflammed synovial lining -synovitis

USG ABDOMEN AND PELVIS (2/7/24)

IMPRESSION: interrnal echoes noted in partially distended urinary bladder

USG PAROTID REGION(3/7/24)

IMPRESSION:

 infectious left parotitis

no abscess  formation 

cervical lymphadenopathy (level 1b)

ECG:

2D ECHO(3/7/24):

-No RWMA

-Trivial tr, no MR/AR

- EF 63

- Good LV systolic function

-No diastolic dysfunction

-No PE/LV clot

-IVC (0.8cms) collapsing.

XRAY 

TREATMENT:

INJ. CEFTRIAXONE 1gm/IV/BD

INJ. DOXYCYCLINE 100mg/IV/BD

INJ. PAN 40mg/IV/OD/8AM

INJ. PCM 500mg/IV/STAT 

TAB PCM 500mg/PO/TID

FINAL DIAGNOSIS: 

?ACUTE RHEUMATIC FEVER