10. Physical Examination
• Vital sign : BT 37. 5 C, PR 125/min, RR 22/min, BP 108/65 mmHg
• Weight 26 kg. (P10-25) Height 141 cm (P25-50)
• General apperance : Alert, active, good consciousness, looked pale,
no jaundice, no cyanosis
• HEENT : moderate pale conjunctivae, anicteric sclerae, pharynx and
tonsil not injected, no malar rash , no oral ulcer , no discoid rash
• Lymph node : not palpable
11. • Respiratory : clear, normal chest contour and movement, trachea in
midline, no adventitious sound
• Cardiovascular : no active precordium, full and regular pulse 2+, normal
S1S2, no murmur
• Abdomen : soft, no distension, normoactive bowel sound, no abdominal
bruit, no hepatomegaly, splenomegaly spleen span 10 cm, no CVA
tenderness
• Extremities : right elbow marked swelling , warm , limit ROM
Left knee and Left ankle marked swelling , warm , limit ROM due to pain
• Neuro : Motor gr.V all, DTR 2+ all, pupil 2mm. RTLBE
16. Pertinent findings
• History
1. Subacute oligoarthritis
2. Prolong fever
3. History of herpes zoster
4. History of left pleural effusion
• Physical examination
1. Oligoarthritis
2. Fever
3. Splenomegaly
4. moderate pale conjunctivae
5. No malar rash
17. Problem list
A 11 years old Thai girl presented with Subacute oligoarthritis
with Prolong fever with splenomegaly
21. Liver function test 29/10/2019
AST (U/L) 16
ALT (U/L) 12
alkaline phosphatase (U/L) 132
total protein (g/dL) 9.1
Albumin (g/dL) 3.6
total bilirubin (mg/dL) 0.33
direct bilirubin (mg/dL) 0.19
22. Urine analysis
Color Light-Yellow
Sp.gr. 1.010
pH 6.5
Nitrite Negative
Protein Neg
Glu Normal
Ketone Negative
Urobilinogen Negative
Bilirubin Negative
Erytrocyte Negative
WBC (/HPF) 0-1
RBC (/HPF) 1-2
Epi (/HPF) 0-1
Bacteria Not seen
23. Special laboratory tests Result
C3 (g/L) 1.4(0.9-1.8)
C4 (g/L) 0.25(0.1-0.4)
Anti dsDNA Negative
ANA Positive 1:320
homogenous pattern
Anti-streptolysin O Negative
PPD skin test negative
Source 06/11/2019
Stool concentration for parasite Not found for parasite, WBC, RBC
32. Ultrasonography of left chest
• The study reveals moderate Lt. pleural effusion. The depth from skin
mark to mid lesion is
• IMP :Moderate Rt. pleural effusion.
35. Coagulogram Reference
range
6/11/2019
APTT (sec) 23.60-28.2 18.6
PT(sec) 10.50-13.3 13.1
INR 1.11
TT(sec) 11.50-13.3 13.4
Hematology 6/11/2019
Reticulocyte count(%) 0.6
Direct antiglobulin test (DAT) 1+
36. RBC: Hypochromic
microcytic anisocytosis 1+
poikiocytosis 1+
microspherocyte few
WBC: 1-2/oil field, no toxic
granule or vacuolization
Plt: adequate, no pale
stained platelets
37. RBC: Hypochromic
microcytic anisocytosis 1+
poikiocytosis 1+
microspherocyte few
WBC: 1-2/oil field, no toxic
granule or vacuolization
Plt: adequate, no pale
stained platelets
40. Liver function test 6/11/2019
AST (U/L) 12.2
ALT (U/L) 12.3
alkaline phosphatase
(U/L)
120
total protein (g/dL) 8.5
Albumin (g/dL) 3.12
total bilirubin (mg/dL) 0.26
direct bilirubin (mg/dL) 0.11
41. Urine analysis
Color Yellow / clear
Sp.gr. 1.011
pH 6.5
Nitrite Negative
Protein Neg
Glu Normal
Ketone Negative
Urobilinogen 1
Bilirubin Negative
Erytrocyte trace
WBC (/HPF) 0-1
RBC (/HPF) 2-3
Epi (/HPF) 0-1
Bacteria few
42. Special laboratory tests Result
Rheumatoid factor(IU/mL) 15.3(0-14)
C3 (g/L) 1.75(0.9-2.1)
C4 (g/L) 0.27(0.1-0.4)
Anti dsDNA
ANA
Lupus anticoagulant Pending
Anti Dnase B Pending
Anti-streptolysin O Pending
7
43. Source 06/11/2019
Stool concentration for parasite Not found for parasite, WBC, RBC
Hemoculture No growth
Throat swab culture Normal flora
TB work up 7/11/2019 8/11/2019 9/11/2019
AFB(Gastric lavage) Negative Negative Negative
Genexpert TB test pending
Culture for TB pending
Viral infection investigation
Anti HIV Negative
VDRL
61. Ultrasonography of whole abdomen
• Diffuse splenomegaly without gross space taking lesion, size 11.4 cm
in length
• Liver in normal size, no evidence of portal hypertension
• No ascites
