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 diagnosis with a treatment plan. 

This is an online E log book to discuss our patient’s de-identified health data shared after taking his guardian’s signed informed consent.

An 18 year old female patient presented to the OPD with chief complaints of vomitings since 5 days.

History of present illness:

Patient was apparently asymptomatic 3 months back, she developed fever which was insidious in onset and relieved on medication ( She used to take paracetamol 4 times a day at 8Am, 12Pm, 4Pm and 8Pm). Later after a week the fever subsided then she started having pain which is of pricking type in the joints (PIP, MCP, wrist, elbow, shoulder joints). Pain relieved on taking medication and relapsed on stopping the medicines. 

History of rash on the face and oral ulcers.

Patient had vomitings 3-4 episodes per day which were non bilious, non projectile and containing food particles.

Past History:

Not a known case of diabetes, hypertension asthma, tuberculosis and thyroid disorders.

Personal History:

Diet: mixed

Decreased appetite since 3 months

Sleep: adequate

Bowel and bladder: Regular

On examination:

Patient it is conscious, coherent and cooperative Well oriented to time, place and person.

Pallor +

Edema +

No Icterus, cyanosis, clubbing, generalised lymphadenopathy.

Temp- afebrile

PR- 80bpm

RR- 17/min

BP- 110/60 mmHg

Systemic examination:

CVS- S1, S2 heard, no murmurs

RS- BAE +, NVBS heard

P/A- soft, non tender,bowel sounds heard

CNS- no focal neurological deficits

Investigations:

Immunology/Serology:

ANCA- Myeloperoxidase- Negative

ANCA- Serine Proteinase 3- Negative

Anti Nuclear Antibody- Positive

Anti ds-DNA Antibody- Positive

Treatment: