19 year old having fever and cough since 15 Days

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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 , h/o alopecia and oral ulcers, 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: not a known case of diabetes, hypertension, CAD,TB, seizures

 Family history: not significant

PERSONAL HISTORY:

Diet-mixed 

Appetite-normal 

Sleep-adequate

Bowel and bladder movements-regular Addictons-none 

GENERAL EXAMINATION:

Patient is conscious, coherent and cooperative. moderately built and nourished.

Pallor-present

Icterus-absent

Clubbing-absent 

Cyanosis-absent 

Generalised lymphadenopathy-absent 

Pedal edema-absent 

Vitals:Temperature- 98.3F

Pulse rate-98bpm

Respiratory rate- 18cpm

Blood pressure -140/90

Spo2- 98%at room air

SYSTEMIC EXAMINATION:

Cardiovascular system:

S1 and S2 heard no murmurs heard 

Central nervous system: 

No focal neurological deficit, cranial nerve

 intactCentral nervous system:

Patient is concious coherent.

Higher mental status-

Cranial nerves- intact

Motor 

   Tone- normal 

   Power- normal

Cerebellar functions-normal 

Respiratory system:Bilateral air entry-present ,Normal vesicular breath sounds-heard

Abdominal examination: soft and non tender, No Hepatomegaly, spleen is not palpable

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.