Case 7

A 19 year old girl diagnosed with SLE with fever and cough.

Hi, I am R. Ramya Keerthana, 3rd sem medical student.This is an online elog book to discuss our patients health data after taking their consent. This also reflects my patient centered online learning portfolio.

Case Scenario
A 19 year old girl diagnosed with SLE came to OPD on August 24th with fever and cough.

Chief Complaint
- fever on and off since 10 days that is not relieved by medication since 1 week
- cough since 10 days

History of Present Illness
- patient was apparently asymptomatic 7 months back, when she had fever associated with joint pains and swelling, which was diagnosed to be SLE
- now, she has complaint of continuous high grade fever since 10 days, with no diurnal variation 
- no history of vomiting, diarrhea or burning micturition 

History of Past Illness
- not a known case of hypertension / diabetes mellitus/ epilepsy/ CAD/ asthma / thyroid disorders 

Personal History
- unmarried 
- occupation: student 
- normal appetite 
- mixed diet
- regular bowels
- normal micturition 
- no known allergies 
- no known addictions 

Family History
- no diabetes mellitus 
- no hypertension 
- no heart disease
- no stroke
- no cancer
- no tuberculosis 
- no asthma
- no other hereditary diseases

Physical Examination
- no pallor
- no icterus
- no cyanosis 
- no clubbing of fingers
- no lymphadenopathy 
- no edema of feet
- no malnutrition 
- no dehydration 

Vitals
- BP: 110/80 mm Hg
- Pulse: 83 bpm
- Respiratory rate: 19 cpm
- Temperature: 104°F
- SPO2: 98% at RA
- GRBS: 102 mg/dl

Systemic Examination
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs

Respiratory System
- no dyspnea
- no wheeze
- trachea position: central
- breath sounds: vesicular

Abdomen
- shape: scaphoid
- no tenderness
- no palpable mass
- no bruits
- no free fluid
- hernias orifices: normal
- liver: not palpable 
- spleen : not palpable
- no bowel sounds
- genitals: normal
- speculum examination : normal
- P/R examination : normal

Central Nervous System
- conscious 
- normal speech
- no neck stiffness
- no Kerning's sign
- cranial nerves: normal
- sensory : normal
- motor: normal
- reflexes: all present bilaterally
- finger nose in coordination: normal 
- knee heel in coordination: normal 
- gait: normal

Investigations

Treatment

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