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

2d echo

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