GENERAL DATA:

Patient’s name: RMSex: Male

Age: 15 years old Civil status: Single
Address: Cainta, Rizal

HISTORY OF PRESENT ILLNESS:

Three years PTA, patient was brought to the clinic because of joint pains. The pain
was initially on the right knee then moved to the left ankle, associated with
intermittent low to moderate fever. He has not been able to walk right due to pain
in his joints. He reports having fever with sore throat, cough and abdominal pain
prior to the onset of joint pains but no rash, conjunctivitis, diarrhea nor dysuria. A
paediatrician saw him who prescribed Amoxicillin, the patient was not compliant
due to financial difficulties.

PAST MEDICAL HISTORY:

He has no history of recurrent infections nor antecedent history of trauma. He has

received the EPI vaccines at the health center when he was less than one.

FAMILY HISTORY:

He has no family history of Rheumatoid Arthritis, SLE, Asthma and malignancy.

HEADSSS:

RM lives with his parents and eight siblings in a 20 square meter rented room that is
poorly –lit and –ventilated, located in an overcrowded area. He is currently a 3rd
year high school student in a public school. He has a girlfriend and admits to being
sexually active. His father is the sole breadwinner and works as a part time
construction worker while his mother stays at home to take care of the children.

PHYSICAL EXAMINATION:
Appears well, fairly nourished, ambulates with assistance, in pain.
VS: BP – 90/60 mm Hg RR- 20 cpm
HR – 121 bpm T – 38.4oC

No rash nor scalp lesions. No nail changes.

No oral ulcers. Tonsils enlarged but not hyperemic and no exudates.
No naso-aural discharge, turbinates not congested.
Intact tympanic membrane.
Supple neck with no enlarged cervical lymph node.
Adynamic precordium, AB at 5th LICS MCL. Grade 2/6 holosystolic apical murmur. No
friction rub.
Symmetrical chest expansion. No retractions. Clear breath sounds.
Flat abdomen with NABS. Non-tender. No mass. No hepatosplenomegaly.
Musculoskeletal exam:
Antalgic gait
 Left ankle – with swelling, warmth, erythema and severe pain even with slight
movement.
Other joints were normal

1. Give the salient features of the patient (based on the historical clinical data
and PE findings).

SALIENT FEATURES
o 15 yrs. old
o Joint pains with low to moderate fever
o Fever with sore throat and cough
o Ambulates with assistance and in pain
o Tonsils enlarged
o Grade 2/6 holosystolic murmur
o Musculoskeletal exam:
 Antalgic gait
Left ankle with swelling, warmth, erythema and severe pain even with
slight movement.