19 year old with fever and cough

 

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A 19 year old girl, hailing from Narketpally,  came to the OPD with chief complaints of fever and cough since 15 days

HOPI:

patient was apparently asymptomatic 7 months back she developed fever, after the fever subscied she started having pain in the small joints PIP, DIP, MIP etc. Subcided with medication and relapse after stopping the medication.patient had h/o of migratory polyarthritis, h/o of dragging type of pain in both lower limbs( ankle joint spared), h/o of decreased appetite for 2 months, h/o pain abdomen ( spasmodic type) for 5 days and not associated with loose stools and there was h/o of vomitings for 2 days non bilious , non projectile containing food particles and headache, which was diagnosed to be SLE

 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

Past history : has no history of allergies , asthma, epilepsy,  TB, any thyroid disorders 

Family History: Not significant

Treatment History: She is on the medication of SLE .She is taking Azathioprine  and  wysolone tablets.

Personal history : She is a student of Bsc nursing 1st year.

Diet ‐ mixed

Appetite ‐ normal 

Sleep ‐ adequate

Bowel and Bladder movements ‐ regular 

General Examination: the patient is conscious,  coherent,  cooperative,  moderately built and nourished.

Pallor,Icterus, cyanosis, clubbing,  generalised lymphadenopathy,  pedal edema are absent. 

Erythematous rash is seen on the nasal bridge and cheeks.

VITALS : 

Temperature ‐ 98.3F

Pulse rate ‐ 98 bpm

BP ‐ 140/90 mmHg

RR 18cpm

SpO2 96%

Systemic examination : 

CVS : S1 , S2 heard, no murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits

Investigations:

Provisional diagnosis: viral pyrexia with know case of SLE

Treatment

1.inj Neomol 1gm iv infusion if fever more than 102 F

2.Tab Dolo 650 mg po/BD

3.Tab PAN 40mg po/ OD BBF

4.IVF 10 NS 100ml hr

5.Wysalone 30 mgOD/PO

6.Tab Azathioprine 50mg PO/OD

7.Temp monitoring every 4 hourly

8.Vitals monitoring every 4 hourly.

25/08/22

Diagnosis:viral pyrexia  under evaluation and known case of SLE.

O/E

Petaiche

Pt. Is conscious coherent and copertative

PR 83 BPM

RR 18 cpm

TEMP 98.7

BP 100/70mmHg

RS :BAE + ,clear

CVS: S1,S2 Heard , no added sounds

CNS :NO abnormalities 

P/A Soft and non tender

Plan of treatment

1.Dolo 650 mg PO/TD

2.Inj ceftrioxone 1mg po/OD

3.Tab cetrizine 10 mg PO/OD

4.GYROP BENADRYL 15m po/OD

5.Tab Azathioprine 50mg po/OD

6.pan 40 mgpo/OD

7.Ivf 10 NS 10 RL @15ml hr

8.Temp monitoring every 4 hourly.

26/08/22

Diagnosis:viral pyrexia under evaluation and known case of SLE.

O/E

Petaiche

Pt. Is conscious coherent and copertative

PR 82 BPM

RR 18 cpm

TEMP 100.4F

BP 110/80mmHg

RS :BAE + ,clear

CVS: S1,S2 Heard , no added sounds

CNS :NO abnormalities 

P/A Soft and non tender

Plan of treatment

1.INJ NEOMOL 1GM IV if temp more than 102 F

2.Tab Dolo 650 mg po/BD

3.Inj ceftrioxone 1gm IV BD

4.Syrup BENADRYL 15mg po/BD

5.Tab Wysalone 30mg po/ OD

6.Tab Azathioprine 50mg po/OD

7.pan 40 mgpo/OD

8.Ivf 10 NS 10 RL @15ml hr

9.Temp monitoring every 4 hourly.

10.Inj piptaz 4.5 gm IV BD.