General Medicine
25,August, 2022
A 19 year old female with (SLE ) came to casuality with fever and cough.
E LOG GENERAL MEDICINE
Hi, I am Pindi Gayatri, 3rd Sem Medical Student.This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent.
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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
CHIEF COMPLAINTS
A 19 year old female came to the casuality with the complaints of fever and cough since 15 days on 24th, August.
HISTORY OF PRESENT ILLNESS
He came to the casuality with the complaints of fever since 15 days on and off not relieved on medication. Cough since 1 week.
Patient was apparently asymptomatic 7 months back ,then she developed fever, after the fever subsided.she started having pain in the small joints PIP, DIP, MIP etc. Subsided with medication and relapse after stopping the medication. She had h/o fever associated with multiple joint pains (wrist joint,elbow joint,shoulder joint,knee joint).High fever spikes,multiple joint pains(small joints of hands---elbow---shoulder) and elbow mild swelling. Loss of appetite and Nausea.Erythematous rash on malar prominence and nasal bridge.vomitings and Nausea after discharge on 7/2/22-could be due to HCQ intolerance.she used T.Onmacortil 10mg for 2-3 days and stopped later due to vomitings.Patient had h/o of migratory polyarthritis, h/o of dragging type of pain in both lower limbs( ankle joint and joints of foot are spared). H/o of decreased appetite for 2 months.H/o pain abdomen ( spasmodic type) for 5 days and subsided, not associated with loose stools . H/o of vomitings for 2-3days ,non bilious , non projectile containing food particles and headache,burning sensation of eyes. H/o alopecia and oral ulcers, which was diagnosed to be SLE.
She was diagnosed with polyarthralgia. ANA,dsDNA positive,low C3,C4.positive coombs test,anemia.
And now she is complaning of fever since 15 days, which is continuous high grade fever associated with chills and rigor, no diurnal variation, no history of vomitings, diarrhoea, burning micturition
HISTORY OF PAST ILLNESS
Known case of SLE.
Not a known case of Diabetes, epilepsy, CAD,Asthma, Thyroid, etc.
TREATMENT/DRUG HISTORY
No Diabetes
NO Hypertension
No CAD
No Asthma
No Tuberculosis
No Antibiotics
No Hormones
No Chemo/Radiation
No Blood transfusion
No surgeries
PERSONAL HISTORY
Single
Occupation- student
Diet-mixed
Appetite-normal
Bowels-regular
Micturition-normal
No drug use, betel nut, betel leaf.
FAMILY HISTORY
Not significant
GENERAL EXAMINATION
No pallor
No icterus
No cyanosis
No clubbing of fingers/toes
No lymphadenopathy
No oedema of feet
No malnutrition
No dehydration
VITALS
Temperature-104°F
Pulse rate-82 bpm
Respiratory rate-19cpm
Blood pressure-130/90 mmHg(left arm)
SpO2 at room air-90%/at RA litres of 02
GRBS-130 mg/dL
SYSTEMIC EXAMINATION
CVS
No thrills
S1S2 sounds heard
No cardiac murmurs
RESPIRATORY SYSTEM
Position of trachea-central
Vesicular breath sounds
No dyspnea
No wheezing
ABDOMEN
Shape of the abdomen-scaphoid
No Tenderness
No palpable mass
Normal hernial orifices
No free fluid
No bruits
Non palpable liver
Non Palpable spleen
No Bowel sounds
CNS
Level of consciousness-conscious/alert
Speech-normal
Signs of meningeal irritation
No stiffness of neck
Kerning's sign:negative
Cranial nerves,motor system,sensory system, glassgow scale-intact.
Reflexes
Biceps Triceps supinator knee ankle
Right + + + + +
Left + + + + +
Plantars-flexor
Cerebral signs
Finger nose In-coordination:yes
Knee heel In-coordination :yes
INVESTIGATIONS
On 20th,August
On 22nd, August
0n 25th, August
RECORDINGS
PROVISIONAL DIAGNOSIS
Viral pyrexia
Known case of SLE.
TREATMENT
