A case of 20 year old famale

 

Name: J. Akash


 9/01/2023






Roll no. 53




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.




Following is the view of my case :


A 20 year old female K/C/O SLE came to casuality with

C/O Fever since 1day

2 episodes of vomitings

Giddiness since 1day

Patient was apparently asymptomatic 5months back

then she was diagnosed as SLE

From today afternoon she is complaining of fever low grade on and off associated with 2 episodes of vomitings non-projectile , non-bilious containing food particles followed by giddiness 

No H/o headache

No h/o burning micturition 

No h/o abdominal pain, distension, constipation, diarrhoea

No h/o dyspnea, orthopnea,PND

No h/o chest tightness,chest pain

PAST HISTORY:

Not a K/C/O DM,HTN,TB,Asthma, epilepsy,CAD

Case of SLE with intraventricular hemorrhage secondery to ?Warfarin induced ? Autoimmune meningitis 

she is on Tab.acetrom 1mg OD and Tab.Azathioprine 50mg and Tab.Prednisalone 20mg Po/BD

PERSONAL HISTORY :

Apetite-normal

Diet-mixed

Sleep-adequate 

Bowel&bladder-regular

no addictions

FAMILY HISTORY: insignificant 

GENERAL EXAMINATION

pt conscious/coherent/co-operative

well orientated to time place person

No signs of pallor, Icterus,clubbing,edema ,cyanosis lymphadenopathy 

BP-120/80 mmhg

PR-102bpm

RR-16cpm

Spo2-98%

GRBS-104mg/dl

CVS- S1S2 heard 

 No thrills & Murmurs

P/A : Soft,non-tender

CNS- No focal deficit 

RS- Tarchea central

     BAE+ , NVBS

PROVISIONAL DIAGNOSIS :

SLE 


INVESTIGATIONS;

USG-ABDOMEN 



2D echo






Chest Xray PA view




ECG




TREATMENT GIVEN: 

on 07/01/23

Inj.neomol 1gm IV/Sos


Tab.Dolo 650mg po/qid


Inj.Zofer 4mg IV/TID


Tab. HCQ 200mg po/OD


Tab.prednisalone 20mg po/BD


Tab.Azathioprine 50mg Po/BD


Tab.Dolo 650mg Po/Qid



08/01/2023

UNIT 5 

DR HIMAJA, PGY1

DR PAVANI, PGY2

DR SAICHARAN, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN


AMC, DAY 1

AGE : 20 GENDER :F



S :

fever subsided

No vomitings

Stools not passed

flatus passed


O:

  pt conscious, coherent, co-operative

  Bp-140/80mmhg

  PR-78bpm

  Temp-98°F

CVS - S1,S2 heard , no added sounds 

RS - BAE + , NVBS

PA - Soft,NT

CNS - No focal deficit

I/O : 700ml/550ml

GRBS: 104mg/dl


A:

SLE 

P:

Inj.neomol 1gm IV/Sos

Tab. HCQ 200mg po/OD

Tab.prednisalone 20mg po/BD

Tab.Azathioprine 50mg Po/BD

Tab.Dolo 650mg Po/BD




09/01/2023

UNIT 5 

DR HIMAJA, PGY1

DR PAVANI, PGY2

DR SAICHARAN, PGY3

DR ABHINAYA, SR

DR AKASH, INTERN

DR HYNDAVI, INTERN

AMC, DAY 2

AGE : 20 GENDER :F


S :

fever subsided

No vomitings

Stools passed


O:

  pt conscious, coherent, co-operative

  Bp-110/90mmhg

  PR-90bpm

  Spo2-97%

  Temp-98°F

CVS - S1,S2 heard , no added sounds 

RS - BAE + , NVBS

PA - Soft,NT

CNS - No focal deficit

I/O : 1200ml/1050ml

GRBS: 110mg/dl


A:

K/C/O SLE with Libmann sachs endocarditis H/o Cardioembolic stroke


P:

Inj.neomol 1gm IV/Sos

Tab. HCQ 200mg po/OD

Tab.prednisalone 20mg po/BD

Tab.Azathioprine 50mg Po/BD

Tab.Dolo 650mg Po/Qid



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