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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