19 year old female with fever since 1week
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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 i reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan
Previous admission
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1701006011
A pavan kumar
19 yr old female came with the chief complaints of
1) fever since 1 week on and off not relieved by medication 2) cough since 1week
HOPI
patient was apparently asymptomatic 7 months back she had fever associated with joint pains and swelling for which she was diagnosed to be SLE and now she c/o fever since 10 days continuous high grade fever associated with chills and rigor
No diurnal variations
No h/o vomiting
No h/o diarrhea burning micturation
Past history:
patient is not a k/c/o DM / HTN / asthma / cad / epilepy
She is a known case of SLE 7months back which she get treated
Personal history :
Appetite -adequate
Diet - mixed
Family history:
No significant family history
O/E
At the time of admission patient was consious coherent and cooperative
On admission vitals are
Bp-. 100/70
Temp -101'F
Pulse rate - 92
Respiratory rate - 20
GRBS - 105 mg/dl
INVESTIGATIONS
Amc bed
Admission 24/8/2022
Day 4 27/8/2022
S: Fever since 10 days
O: Fever spikes present
Pr-96 bpm
BP-100/80 mmhg
Grbs 80mg/dl
CVS s1 s2+
Rs bae+
Cns higher motor functions intact
Pa soft and non tender
A: pyrexia under evaluation with known case of SLE
P:
Inj neomol 1gm iv/sos if temp >101f
Inj piptaz 2.5 gm iv bd
Tab dolo 650mg Po qid
Tab pan 40mg Po od
Tab wysolone 30mg Po od
Tab azithromycin 50mg Po od
Syp. Benadryl 15ml Po bd
Temp monitoring 4th hourly
DIAGNOSIS
Viral pyrexia under evaluation with k/c /o SLE
TREATMENT
1) TAB DOLO 650mg PO BD
2) INJ CEFTRIAXONE 1gm iv BD
3) TAB CEFTRIAXONE 10 MG PO OD
4) SYRUP BENADRYL 15ml po tid
5) TAB AZATHIAPRINE 50 MG PO OD
6) TAB PAN 40 PO OD
7) IVF 10NS 10RL 75 ML/HR
8) TEMPERATURE MONITORING 4TH HOURLY
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