Case based OSCE -31 yr old female with fever since 5 months

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I have 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 diagnosis and treatment plan

The patient/ attender was informed the purpose of the information being acquired. An informed consent was taken from patient/ attender and there is omission of information that was requested to be omitted. 

CHIEF COMPLAINTS 

A 31 year female came with chief complaints of fever since 5 months

Fever is high grade associated with chills and rigor 

It is intermittent in nature

No diurnal variation

It is associated with vomiting , food as content , no bilious , non projectile , no blood stained  

H/o loss of appetite & weight loss +

H/o burning sensation over the tongue and buccal mucosa since 3-4 months, insidious in onset, gradually progressive, aggravated when patient consumes spicy food and no relieving factors

No h/o cough, cold

No h/o chest pain , sob, orthopnea, pnd

No h/o loose stools, constipation

No h/o burning micturition, increased/decreased urine output.

PAST HISTORY

Not a known case of hypertension, DM, asthma, tuberculosis, epilepsy, CVA, CAD.

GENERAL EXAMINATION

Patient is conscious coherent cooperative  moderately built and nourished 

Mild Pallor ,No Icterus Clubbing Cyanosis  Edema 

Vitals : 

PR  : 76 bpm

BP : 110/70 mmHg 

RR : 20 CPM

Temperature : 101f

Spo2 : 98 %

GRBS : 92mg /dl

SYSTEMIC EXAMINATION

CVS : S1 and S2 heart sounds heard

CNS: NO focal neurological deficits 

RR: BAE Present, normal vesicular breath sounds heard,no adventitious sounds

shape of the chest: normal

trachea appears to be central

Per abdomen: soft, non tender

Coated tongue

Butterfly rash

Chest x-ray 

Fever chart

INVESTIGATIONS 

•How do you approach a case of fever?

A- firstly try to rule out common diseases like malaria, dengue, TB, enteric fever and by routine investigations like Hb, total count, platelet count, ESR , CRP, culture and sensitivity,  which may detect any infections, malignancies.

Serological investigations - widal test, malaria,vdrl,dengue, ANAs , HIV Elisa.

•what are the signs & symptoms you observed in this case 

A- recurrent fever, fatigue, mucosal lesions ( oral ulcers), butterfly rash, renal calculi, anemia, poor concentration 

i.e, multisystem involvement pointing towards SLE.

• How can you differentiate malar rash from other  skin lesions

A- It usually involves cheeks and nasal bridge sparing the rest of the face which may be triggered by sunlight.

Unlike other lesions there is no presence of papules/pustules.

• how did you confirm the diagnosis?

A- ANA testing for antibodies like anti smith , anti ds dna

• what other diseases test positive for ANA

A- Rheumatoid arthritis

     Scleroderma

     Sjogren syndrome

•Antibodies detected in this case?

- SmD1 antigen, u1- snRNP antigen, nucleosome antigen, ku antigen

•Treatment given during the stay in the hospital?

-1. IV FLUIDS NS RL @50ML/HR

2. INJ . PCM 1GM IV /SOS IF TEMP >101F

3. TAB. PCM 650 MG PO TID

4. INJ ZOFER 4MG IV/ TID

5. ZYTEE GEL FOR L/A BD

6. 2% BETADINE GARGLES 5ML DILUTED IN 1 GLASS OF WATER 3 TIMES A DAY

7. TAB . MVT PO OD

8. TAB. PREDISOLONE 40 MG PO OD

9. TAB SHELCAL CT PO OD .

PROVISIONAL DIAGNOSIS -

Systemic lupus erythematosus , adjustment disorder