CASE:

A 20-year-old female from Tondo, Manila came in with a chief complaint of fever.

4 weeks prior to consult, patient noted odynophagia, hoarseness of her voice and low-grade fev
er. Patient rested and self-medicated with Lagundi and Paracetamol, which resolved symptoms af
ter 5 days.

For the interim, she was apparently well and able to go back to her daily activities until 2 week
s prior to consult when she noted development fever, Tmax 40ºC, associated with body malaise,
and severe joint pain on the ankles and dyspnea. She self-medicated with Paracetamol with no
relief of symptoms. The following day, she noted resolution of joint pain in her ankles but now
had them in her knees and elbows. No consult was done at this time.

1 week prior to consult, the patient noted persistence of all symptoms. She also noticed develop
ment of rashes on her stomach and arms which she described as “parang bilog na mapa, mapu
la sa gilid pero wala sa gitna,” which spontaneously resolved after 3 days. Persistence of all sym
ptoms prompted consult.

Past Medical History:

Previously confined for “problema sa puso” when she was in Grade 1, lost to follow up

Unrecalled vaccination history

No known allergies or previous surgeries

Family Medical History:

No history of diabetes, hypertension, cancer, tuberculosis

(+) Typhoid fever — brother

(+) Myocardial Infarction — mother

(+) Tuberculosis — father

Review of Systems:

(+) 2 pillow orthopnea

(-) Paroxysmal nocturnal dyspnea

(+) Cough, nonproductive

(-) Abdominal pain

(-) Pallor

(-) Fatigue

(-) Edema

(+) Weight Loss

Personal and Social History:

The patient is a fish vendor. She currently lives with her live-in partner and his family. She does
not smoke but drinks alcoholic beverages (beer) at least a month. She denies illicit drug use. S
he was unable to finish grade school because she was always absent due to “ubo at sipon.”

OB History:

Patient is a G1P1 (1001), with menarche at 13 years old, regular monthly interval of at least 3-4
days, consumes 3 pads per day, no oligomenorrhea. Her first child is a boy delivered via sponta
neous vaginal delivery with no fetomaternal complications. She gave birth at a lying-in clinic nea
r their home.

PE Findings: GREEN - Normal | RED - Abnormal

General: conscious, coherent, in mild respiratory distress, weak-looking

Vital Signs: BP 120/80 mmHg -- elevated (if based sa 2018 JNC 8 BP Guidelines); HR 120 bpm;
RR 26 cpm; Temp 40ºC

Skin and Extremities: no visible skin lesions, (+) erythematous, tender and swollen bilateral knees
and elbows, (+) 0.5x0.5 cm painless nodules on bony prominences of elbows and hands
HEENT: pink palpebral conjunctiva, pupils reactive to light, no cervical lymphadenopathy

Chest: symmetrical chest expansion, (+) fine crackles on bilateral basal lung fields

Heart: (-) precordial bulging, tachycardic, regular rhythm, (+) gr 3/6 holosystolic murmur at apex

Abdomen: soft, nontender abdomen, normoactive bowel sounds

Lab

Clinical Impression:

ACUTE, RECURRENT, RHEUMATIC FEVER