1. FEVER FOR
EVALUATION
Dr N.Samatha,
(MD)INTERNAL MEDICINE

2. Chief complaints
• Mrs Vijaya, 31 yrs female, a House wife,
Presented on 12/12/2011 with C/O
Fever : 2 months
Malar rash : 45 days
Headache : 45 days

3. History of present illness
 Patient was apparently asymptomatic 2 months back
when she developed fever associated with generalised
body pains, rash on palms,back and arms, joint
pains, anorexia, sleeplessness and headache.
• Patient presented to a local hospital, treated
symptomatically, fever was relieved on medication and
was discharged.
• 10-15 days later she developed malar rash,and persistent
fever.
• Then, she presented to Esra hospital with fever and malar
rash.

4. History of present illness
• Fever was intermittent, low grade, on and off, no
chills/rigors, associated joint pains mostly involving large
joints[non migratory and non fleeting]
• From day1 of fever, she developed macular erythema on
palms, upperback and extensor aspect of arms and 10-15
days later she developed malar rash,which is slightly
raised erythematous rash on cheek and nose, precipitated
by sun exposure and non pruritic.
• No history S/O purpura, no orogenital eruptions or scaly
lesions on anyother part of the body.

5. History of present illness
• No past H/O exposure to C/O TB,mite bite,tick bite,or
exposure to rats or cats
• No history S/O malaria,chikungunya,dengue,typhoid
• No history of visual disturbances,altered sensorium & no
complaints S/O motor or sensory impairment
• No H/O cough or dyspnoea
• No history of drug allergy
• No H/O similar complaints in the past

6. Personal/family history
• Mixed diet,decreased appetite,decreased sleep
• Bowel and bladder habits regular
• Menstrual history-menarche at 13,cycles regular,4/30,no
dysmenorrhea,no clots
• No similar complaints in the family

7. General examination
• Patient is conscious, coherent, cooperative, comfortably
sitting on bed, well oriented to time, place & person
• Weight - 56kgs,BMI - 158 cms
• Pallor +,no icterus no cyanosis,no clubbing,no
lymphadenopathy,no pedal edema
• Normal hair
• Malar rash on face ,macular erythema on palms and
back,non-discoid,non blanchable
• No orogenital ulcers
• EYES appear normal O/E
• URT normal,no congestion or secretions noted

9. Physical examination
• Vitals ,BP 110/80, PR 80b/m,regular,normal
volume,character, all peripheral pulses felt.
Temp 100F , RR 16/min
• RS-BAE+,NVBS,no ADV sounds
• CVS-S1,S2 heard,no murmers
• P/A-soft ,no tenderness,no organomegaly,BS+
• CNS-NFND,Plantars-flexor
• Muskuloskeletal system examination-no swelling or
redness or tenderness over large or small joints,no
limitation of movements at joints,no pain,no stiffness

10. Provisional diagnosis
Pyrexia for evaluation
? Connective tissue disorder
? Granulomatous disease
? Enteric fever
? Malignancy

11. Investigations
CBP - HGB:10.7gm%,WBC-1,700/cu.mm, plt-
89,000,N69,M5,L10,E2
PS - Normocytic normochromic,leucopenia,lymphopenia
CUE - Pus cells-0-1,no rbc,no cystals,no casts
LFT - Sr bilirubin-1.08,SGOT-
134U/L, Sr albumin-
4.3gm/dl,ALP-WNL
RFT -NORMAL
Sr electrolytes - Sr Na-146/k-3.9/Cl-100
Chest xray - Normal
ESR -26/55mm

12. Investigations
VDRL- NR
Widal test- Negative
Dengue NS1 Ag &IgM, IgG -Negative
HBs Ag/Anti HAV/Anti HCV /Anti HEV- Negative
HIV - NR
USG ABD/Pelvis - Normal
ANA - POSITIVE(2.975)
Anti ds DNA Antibodies-positive(233IU/ml)

13. Criteria for SLE
1. MALAR RASH
2. Discoid Rash
3. PHOTOSENSITIVITY
4. Oral ulcers
5. Arthritis
6. Renal disorder
7. HEMATOLOGICAL DISORDER
8. Serositis
9. Neurological disorder
10. IMMUNOLOGICAL (Anti-Sm, and/or
anti-phospholipid, Anti dsDNA)
11. ANTINUCLEAR ANTIBODIES-ANA POSITIVE

14. Diagnosis
SYSTEMIC LUPUS ERYTHEMATOSIS

15. Management
Supportive therapy given,inj.methylprednisolone given,
At discharge, T.azathioprine,added at 2mg/kg/day, along
with oral prednisolone,40mg bid
At follow up, patient cell counts improved, rash faded
comparatively, but complained of alopecia,GI symptoms