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.




PAST HISTORY

She has a known complaints of Grade 3  Oesophageal varices 4 years back - EVL done


* She is not a known case of HTN, Diabetes Mellitus , Epilepsy, Thyroid , TB etc...




PERSONAL HISTORY




           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.


VITALS:-

VITALS ON 01.11.2021

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




SYSTEMIC EXAMINATION


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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