fever projr sle 21/F

 sle - 

date of admission 7/1/2023 

date of discharge 9/1/2023



A 20 year old female K/C/O SLE came to casuality withC/O Fever since 1day2 episodes of vomitingsGiddiness since 1dayPatient was apparently asymptomatic 5months backthen she was diagnosed as SLEFrom 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 giddinessNo H/o headacheNo h/o burning micturitionNo h/o abdominal pain, distension, constipation, diarrhoeaNo h/o dyspnea, orthopnea,PNDNo h/o chest tightness,chest painPAST HISTORY:Not a K/C/O DM,HTN,TB,Asthma, epilepsy,CADCase of SLE with intraventricular hemorrhage secondery to ?Warfarin induced ? Autoimmune vasculitisshe is on Tab.acetrom 1mg OD and Tab.Azathioprine 50mg and Tab.Prednisalone 20mg Po/BDPERSONAL HISTORY :Apetite-normalDiet-mixedSleep- adequateBowel&bladder-regularno addictionsFAMILY HISTORY: insignificantGENERAL EXAMINATIONpt conscious/coherent/co-operativewell orientated to time place personNo signs of pallor, Icterus,clubbing,edema ,cyanosis lymphadenopathyBP-120/80 mmhgPR-102bpmRR- 16cpmSpo2-98%GRBS-104mg/dlCVS- S1S2 heardNo thrills &MurmursP/A : Soft,non-tenderCNS- No focal deficitRS- Tarchea central BAE+ , NVBSCOURSE IN THE HOSPITAL; PATIENT WAS BROUGHT TO CASUALITY WITH ABOVE MENTIONED COMPLAINTS,SYMPTOMATICALLY MANAGED AND TAPERED THE DOSE OF PREDNISALONE.ONE UNIT OF FFP TRANSFUSED ON 8TH JANUARY .SYMPTOMS SUBSIDED.PATIENT IS HEMODYNAMICALLY STABLE AND PLAN FOR DISCHARGE.TAB.ACETROM IS WITHHOLDED I/V/O ABNORMAL PT/INROBG REFERRAL WAS DONE I/V/O AMENORRHEA SINCE 2MONTHS AND ADVISE FOLLOWED

INVESTIGATIONS 


Name

 Value

 Range

 Name

 Value

 Range

 BLOOD UREA 07- 35 mg/dl 42-12 mg/


SERUM ELECTROLYTES (Na, K, C l)

07-01-2023 04:38:PM

145-136 mmol/L

5.1-3.5 mmol/L

98-107 mmol/L

SODIUM

POTASSIUM

CHLORIDE

128 mmol/L

3.7 mmol/L

98 mmol/L

 LIVER FUNCTION TEST (LFT)

07-01-2023 04:38:PM

1-0 mg/dl

0.2-0.0 mg/dl

31-0 IU/L

34-0 IU/L

98-42 IU/L

8.3-6.4 gm/dl

5.2-3.5 gm/dl

Total Bilurubin

Direct Bilurubin

SGOT(AST)

SGPT(ALT)

ALKALINE PHOSPHATASE

TOTAL PROTEINS

ALBUMIN

A/G RATIO

0.66 mg/dl

0.18 mg/dl

27 IU/L

43 IU/L

116 IU/L

5.2 gm/dl

3.4 gm/dl

1.91

 PERIPHERAL SMEAR 07-01-2023 04:38:PM

RBC : Normocytic normochromic WBC : With in normal limits with lymphocytosis

PLATELET : Adequate IMP : Normocytic normochromic anemia with lymphocytosis

 HBsAg-RAPID 07- Negative 01-2023 04:38:PM

 Anti HCV Antibodies Non Reactive - RAPID 07-01-2023

04:38:PM

 HIV 1&2 ELISA 07- Non Reactive 01-2023 04:38:PM

 SERUM ELECTROLYTES (Na, K, C l)

08-01-2023 10:37:PM

145-136 mmol/L

5.1-3.5 mmol/L

98-107 mmol/L

SODIUM

POTASSIUM

CHLORIDE

136 mmol/L

4.0 mmol/L

101 mmol/L



Treatment Given(Enter only Generic Name)

1)Inj.neomol 1gm IV/Sos

2)Tab. HCQ 200mg po/OD

3)Tab.prednisalone 20mg po/BD

4)Tab.Azathioprine 50mg Po/BD

5)Tab.Dolo 650mg Po/Qid

6)Inj.Vit k 1amp in 100ml NS

7)inj.zofer 4mg iv/tid

Follow Up

REVIEW AFTER 1 WEEK TO MEDICINE OP WITH PT/INR REPORTS


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