30 YR OLD FEMALE WITH FEVER AND COUGH

202418444 jyothi
CASE HISTORY AND CLINICAL FINDINGS
C/O OF FEVER SINCE 10 DAYS
C/O OF COUGH SINCE 10 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK ,THEN DEVELOPED FEVER
,SUDDEN IN ONSET ,CONTINUES TYPE ,A/W WITH CHILLS ,H/O COUGH ,PRODUCTIVE TYPE
,WHITISH SPUTUM SINCE 1 DAY .H/O OF NAUSEA PRESENT ,H/O OF DYSPHAGIA WITH
STOMATITIS AND GLOSSITIS
NO H/O OF SHORTNESS OF BREATH ,CHEST PAIN ,VOMITING ,LOSS OF CONSIOUSNESS ,
NO H/O OF PALPITATIONS ,DIZZINESS ,HEADCHE
GENERAL EXAMINATION
PATIENT IS C/C/C
NO PALLOR ,ICTERUS, CYANOSIS ,CLUBBING ,LYMPHADENOPATHY ,OEDEMA OF FEET
VITALS
BP 100MMHG
PR 86 BPM
RR 23 CPM
TEMPERATURE 98.8 F
STSTEMIC EXAMINATION
RS ; BAE PRESENT , NVBS
CVS ;S1 ,S2 HEARED
CNS ; NFND
PA ; SOFT NON TENDER
REFERRAL DONE BY PSYCHIATRY I/V/O ADJUSTMENT DISORDER
ADVICE-
TAB MIRTAZEPINE 7.5 MG 0-0-1
REFERRAL DONE BY OPTHALMOLOGY I/V/O VAWSCULITIS
ADVICE-
FUNDUS FLUROSCEIN ANGIOGRAPHY AND OCT
REFERRAL DONE BY ENT I/V/O ORAL CANDIDIASIS
ADVICE-
2%BETADINE GARGLES [DILUTED] 3-4 TIMES /DAY X 5 DAYS
COURSE IN THE HOSPITAL
30 YR OLD FEMALE CAME WITH COMPLAINTS OF FEVER SINCE 10 DAYS .ON DAY OF
ADMISSION PT WAS IRRITABLE.ON EVALUATION IN PREVIOUS ADMISSION PATIENT WAS
FOUND TO HAVE ANTIBODIES DETECTED AGAINST smD1 ANTIGEN WITH AN INDEX 5.96 AND
INTERPRETATION (+++)U1-snRNP ANTIGEN WITH INDEX 4.80 AND INTERPRETATION (+++)
NUCLEOSOME ANTIGEN WITH INDEX 1.57 AND INTERPRETATION (+)KU ANTIGEN WITH AN
INDEX 1.00 AND INTERPRETATION IS BORDER POSITIVE IN PREVIOUS ADMISSION.PATIENT
HAD CLINICAL FEATURES OF SLE FOR WHICH PREDNISOLONE 40 MG WAS STARTED BUT
PATIENT WAS NON COMPLIANT TO DRUGS.SO SHE WAS AGAIN STARTED WITH
PREDNISOLONE.OPTHALMOLOGYBREFERRAL WAS TAKEN I/V/O DOV NOTICED
VASCULITIS,SO MRI BRIAN WAS DONE I/V/O VASCULITIS BUT NO ABNORMALITY WAS
DETECTED PSYCHIATRY OPINION WAS TAKEN I/V/O IRRITABLE BEHAVIOUR FOR WHICH
APPROPRIATE TREATMENT WAS GIVEN . PATIENT WAS IMPROVING CLINICALLY BUT
NEEDS FURTHER EVALUATION FOR ?LUPUS NEPHRITIS.BIOPSY WAS DONE ON 2/05/2024 ,
REPORTS ARE YET TO COME ,BUT PATIENT AND PATIENT ATTENDERS ARE NOT WILLING
TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVISE .
Investigation
NameValueRangeNameValueRangeLIVER FUNCTION TEST (LFT) 25-04-2024 06:30:PM
Total Bilurubin
0.53 mg/dl1-0 mg/dl
Direct Bilurubin
0.19 mg/dl0.2-0.0 mg/dl
SGOT(AST)
203 IU/L31-0 IU/L
SGPT(ALT)
74 IU/L34-0 IU/L
ALKALINE PHOSPHATASE
143 IU/L98-42 IU/L
TOTAL PROTEINS
7.6 gm/dl8.3-6.4 gm/dl
ALBUMIN
3.0 gm/dl5.2-3.5 gm/dl
A/G RATIO
0.67
BLOOD UREA25-04-2024 06:30:PM38 mg/dl42-12 mg/dl
SERUM CREATININE
25-04-2024 06:30:PM0.8 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 25-04-2024
06:30:PM
SODIUM
132 mmol/L145-136 mmol/L
POTASSIUM
3.9 mmol/L5.1-3.5 mmol/L
CHLORIDE
102 mmol/L98-107 mmol/L
HBsAg-RAPID25-04-2024 06:30:PM
Negative
Anti HCV Antibodies - RAPID
25-04-2024 06:30:PMNon Reactive COMPLETE BLOOD PICTURE (CBP) 26-04-2024 12:27:AM
HAEMOGLOBIN
9.5 gm/dl15.0-12.0 gm/dl
TOTAL COUNT
3000 cells/cumm10000-4000 cells/cumm
NEUTROPHILS
80 %80-40 %
LYMPHOCYTES
17 %40-20 %
EOSINOPHILS
00 %6-1 %
MONOCYTES
03 %10-2 %
BASOPHILS
00 %2-0 %
PLATELET COUNT
1.52SMEARNormocytic normochromic anemia with leucopeniaCOMPLETE URINE EXAMINATION
(CUE) 27-04-2024 01:05:PM
COLOUR
Pale yellow
APPEARANCEClear
REACTION
Acidic
SP.GRAVITY
1.010
ALBUMIN
++++
SUGAR
Nil
BILE SALTS
Nil
BILE PIGMENTS
Nil
PUS CELLS
3-4
EPITHELIAL CELLS
2-3
RED BLOOD CELLS
Nil
CRYSTALS
Nil
CASTS
Nil
AMORPHOUS DEPOSITS
Absent
OTHERS
NilCOMPLETE BLOOD PICTURE (CBP) 27-04-2024 11:41:PM
HAEMOGLOBIN
9.1 gm/dl15.0-12.0 gm/dl
TOTAL COUNT
5000 cells/cumm10000-4000 cells/cumm
NEUTROPHILS
80 %80-40 %
LYMPHOCYTES15 %40-20 %
EOSINOPHILS
00 %6-1 %
MONOCYTES
05 %10-2 %
BASOPHILS
00 %2-0 %
PLATELET COUNT
1.2SMEARNormocytic normochromic anemia with mild thrombocytopenia
HEMOGRAM ON 25/4/24
HEMOGLOBIN-8.6
TC-3000
RBC-3.6
PLATELETS - 1.7
ON 26/4/24
HB-9.5
TC-3000
PLATELET -1.52
ON 27/4/24
HB-10.5
TC-4000
PLATELET-1.20
RBC-4.36
ON 28/4/24
HB-9.1
TC-5000
PLATELET-1.2
ON 29/4/24
HB-9.8
TC-4000
PLATELET-1.5
IMPRESSION:MICROCYTIC HYPOCHROMIC ANEMIA
30/4/24
HB-11.4TC-3000
PLATELETS-80000
IMPRESSION:NORMOCYTIC NORMOCHROMIC WITH FER MICROCYTES
HEMOGRAM ON 30/4/24
HEMOGLOBIN-8.9
TC-4000
RBC-3.65
PLATELETS - 80000
HEMOGRAM ON 1/5/24
HEMOGLOBIN-8.6
TC-4000
RBC-3.65
PLATELETS - 1.4
HEMOGRAM ON 2/5/24
HEMOGLOBIN-9.5
TC-4000
RBC-4.04
PLATELETS - 1.4
ESR ON 28/4/24 - 62
RFT ON 30/4/24
UREA - 44
CREAT - 0.7
SODIUM - 135
POTASSIUM - 4.7
CHLORIDE - 102
IONISED CALCIUM - 1.12
MRI BRAIN ON 27/4/24- NO ABNORMALITY DETECTED
STOOL FOR C/S ON 26/4/24
NO OVA OR CYSTS SEENNO PATHOGENIC ORGANISM ISOLATED
URINE FOR C/S ON 29/4/24
0-1 PUS CELLS SEEN
POLYMICROBIAL FLORA GROWN
USG ON 26/4/24
NO SONOLOGICAL ABNORMALITY DETECTED APART FROM B/L TINY RENAL CALCULI
24H URINE PROTEIN TO CREATINE RATIO - 0.30
24 HR PROTEIN - 242
24 HR CREATININE - 0.8
URINE VOL - 800 ML
RENAL BIOPSY WAS DONE ON 3/05/24 REPORTS ARE YET TO COME
REVIEW USG WAS DONE ON 4/4/24 I/V/O ANY COLLECTIONS POST BIOPSY -
NO COLLECTIONS WERE NOTES IN PERI RENAL REGION
DIAGNOSIS
K/C/O SYSTEMIC LUPUS ERYTHAMATOUSUS FLARE UP SECONDARY TO NON COMPLIANCE
TO DRUG WITH LUPUS NEPHRITIS WITH ADJUSTMENT DISORDER
TREATMENT GIVEN
IVF NS/RL @ 75ML/HR
INJ NEOMOL 1 GM IV BD
INJ PAN 40 MG IV OD
INJ ZOFER 4 MG IV SOS
INJ OPTINEURON 1 AMP IN 100ML NS
TAB FLUCONAZOLE 150 MG OD PO X 1 DAY
INJ MONOCEF 1 GM IV BD
TAB . WYSOLONE 40 MG PO BD X 9 DAYS
CANDIDA MOUTH PAINT L/A TID FOR 1 DAY
TAB .PCM 650 MG PO QID 6 DAYS
TAB .MIRTAZIPINE 7.5 MG PO HS
TAB CLONAZEPAM 0.25 MG IF PATIENT IS ANXIOUS AND /IRRITABLE/HELPLESS
ADVICE AT DISCHARGE
LAMA NOTES
PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT THAT IS, SYSTEMIC LUPUS ERYTHEMATOUS WITH LUPUS NEPHRITIS WITH
ADJUSTMENT DISORDER AND ITS RISK AND COMPLICATIONS ASSOCIATED WITH IT IN
THEIR OWN UNDERSTANDABLE LANGUAGE[TELUGU]. PATIENT AND PATIENT ATTENDERS
ARE REFUSING FOR FURTHER INVESTIGATIONS AND TREATMENT INSPITE OF EXPLAINING
THE RISK AND COMPLICATIONS, PATIENT AND PATIENT ATTENDERS WANT TO LEAVE
AGAINST MEDICAL ADVICE.
DOCTORS, STAFF, MANAGEMENT ARE NOT RESPONSIBLE FOR ANY UNTOWARD EFFECTS
TO THE PATIENT INCLUDING CARDIAC ARREST.

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