MEDICINE CASE DISCUSSION
48 year old female with history of Fever with chills and rigor
November 3 , 2021
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P.Manasa
Roll no:- 102
9th semester
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
I have 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 diagnosis and treatment plan.
CASE:-
48 year old lady resident of Nalgonda , farmer by occupation brought to the OPD with Cheif complaints of Fever with chills and rigor not subsided on medication.
* Fever since 3days
HISTORY OF PRESENTING ILLNESS :-
FEVER
- High grade fever
- Insidious in onset
- Intermittent in nature
- Duration = 3days
- Associated with chills and rigor and jaundice
- No history of vomiting ,pain abdomen
- No Aggravating factors
- Not Relieved on taking medications.
DIET - MIXED
APPETITE - NORMAL
BOWEL &BLADDER - REGULAR
SLEEP - ADEQUATE
NO ADDICTIONS
NO H/O DRUG ALLERGIES.
FAMILY HISTORY
No history of similar complaints in the family.
GENERAL EXAMINATION
* Patient was examined in well light and good ventilation room.
*Patient has altered sensorium and not responding to commands.
* Moderately built and Moderately nourishment.
Pallor - Present
Icterus- Present
No Cyanosis
No Clubbing
No Bilateral pedal oedema
No Lymphadenopathy.
Temperature = 99.6 F
Pulse rate = 80 beats permin
Respiratory rate = 20 cycles/min
Blood pressure = 110/70 mm of Hg
Spo2 = 99% at room air
GRBS = 89 mg/dl.
VITALS ON 02 .11 .2021
*Temperature = 98.4 F
Pulse rate =82beats permin
Respiratory rate = 22cycles permin
Blood pressure = 130/80 mm of Hg
Spo2 = 97% at room air
GRBS = 127mg/dl.
VITAL ON 03.11.2021
Temperature = 97.6 F
Pulse rate = 68beats permin
Respiratory rate = 16 cycles permin
Blood pressure = 110/70 mm of Hg
Spo2 = 98 % at room air
GRBS = 115 mg/dl
On 04.11.2021
Temperature = 98.6 F
Pulse rate = 86beats permin
Respiratory rate = 21cycles permin
Blood pressure = 110/90 mm of Hg
Spo2 = 98 % at room air
GRBS = 99 mg/dl
On 05.11.2021
Temperature = 98.6 F
Pulse rate = 83beats permin
Respiratory rate = 22 cycles permin
Blood pressure = 120/80 mm of Hg
Spo2 = 98 % at room air
GRBS = 156 mg/dl
TPR GRAPHIC SHEET
* CVS - S1 , S2 sounds heard
No murmurs.
* Respiratory system
~Normal vesicular breath sounds heard
~ Bilateral air entry present (BAE+ve)
* Abdomen
Mass per Abdomenand Non Tender
Bowel sounds normal
Splenomegaly is present .
* CNS
No Neurological deficits are seen
No signs of meningial irritation
INVESTIGATIONS
patient. referred to Ophthalmology
Slit lamp examination
* Any Retinal vasculitis, Bullous keratopathy
Inference :- No features of Bullous Maculopathy are seen
Treatment - HCQ
PROVISIONAL DIAGNOSIS
Febrile Neutropenia with Thrombocytopenia and anemia
SLE flare up/Infection secondary to discontinuation of medication.
k/c/o SLE with portal vein thrombosis and pancytopenia
TREATMENT HISTORY
On 01.11.2021
TAB . PROPRONAL 20mg/PO/H/S
TAB . HCQ 200mg/PO/H/S
TAB . PREDNISOLONE 5mg/PO/OD
TAB. FOLATE 5mg/PO/OD
T. PANTOP 40mg/PO/OD
T. SHELCAL 500mg/PO/OD
T. AUGMENTIN 625mg/PO/BD
On 02.11.2021
TAB . PROPRONAL 20mg/PO/H/S
TAB . HCQ 200mg/PO/H/S
TAB . PREDNISOLONE 5mg/PO/OD
TAB. FOLATE 5mg/PO/OD
T. PANTOP 40mg/PO/OD
T. SHELCAL 500mg/PO/OD
T.PRO AUGMENTIN 625mg/PO/BD
INJ.DOXYCYCLINE 100mg/IV/BD
TAB. CIPROFLOXACIN 500mg/PO/BD
On 03.11.2021
TAB . PROPRONAL 20mg/PO/H/S
TAB . HCQ 200mg/PO/H/S
TAB . PREDNISOLONE 5mg/PO/OD
TAB. FOLATE 5mg/PO/OD
T. PANTOP 40mg/PO/OD
T. SHELCAL 500mg/PO/OD
T.PRO AUGMENTIN 625mg/PO/BD
INJ.DOXYCYCLINE 100mg/IV/BD
TAB. CIPROFLOXACIN 500mg/PO/BD
TAB .MVT OD
On 04.11.2021
TAB . PROPRONAL 20mg/PO/H/S
TAB . HCQ 200mg/PO/H/S
TAB . PREDNISOLONE 5mg/PO/OD
TAB. FOLATE 5mg/PO/OD
T. PANTOP 40mg/PO/OD
T. SHELCAL 500mg/PO/OD
T.PRO AUGMENTIN 625mg/PO/BD
INJ.DOXYCYCLINE 100mg/IV/BD
TAB. CIPROFLOXACIN 500mg/PO/BD
TAB .MVT OD
TAB .ACITRAM 2mg/PO/OD
On 05.11.2021
TAB . PROPRONAL 20mg/PO/H/S
TAB . HCQ 200mg/PO/H/S
TAB . PREDNISOLONE 5mg/PO/OD
TAB. FOLATE 5mg/PO/OD
T. PANTOP 40mg/PO/OD
T. SHELCAL 500mg/PO/OD
T.PRO AUGMENTIN 625mg/PO/BD
INJ.DOXYCYCLINE 100mg/IV/BD
TAB. CIPROFLOXACIN 500mg/PO/BD
TAB .MVT OD
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