PATIENT’S DATA:

Name: Nur Rulhuda Bt. Mohd. Yurid, I/C No.: 890110-06-5866, Gender:
Female, Race: Malay, Age: 20 years old, Date of Admission: 16 September
2009, Date of Clerking: 17 September 2009, Source of information: Patient

PRESENTING COMPLAINT:
She was complaint of sudden onset of prolonged fever for 1 month associated
with chills and rigor and chronic non-productive cough.

HISTORY OF PRESENTING COMPLAINT:

She was apparently well before she had sudden onset of constant fever for
the past 1 month associated with dry cough. She claimed that she was afebrile
during daytime but the fever becomes worse at night by the presence of chills and
rigor and also by chronic non-productive cough which awake her from sleep.
There were also headache, giddiness, palpitation, retro orbital pain but no chest
pains, no dyspnoea, no syncope, no nausea and vomiting, no bilateral leg
swelling, no body ache, no arthralgia, no myalgia, no sore throat and cold. This
problem was not relieved by antibiotics and fever medications.
She lost her appetite since 1 month ago and she lost 4 kg within that time.
Since 1 month ago, she went to five clinics but she was only given antibiotics and
medications for fever until the GP of one of the clinic she went noticed that she
had proteinuria and referred her to this hospital immediately.
She had history of hospital admission last two years for the same reason
and then when she was diagnosed having SLE. She rarely went outside her house
as she is photophobic and she will develop rashes when exposed to the sunlight.
Mostly her meal were home made.

SYSTEMIC REVIEW:
Cardiovascular system: There was palpitation but no chest pain, orthopnea and
paroxysmal nocturnal dyspnoea. Respiratory system: She had non-productive cough
worsen at night, but no shortness of breath. No heamoptysis. Gastrointestinal system:

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there was epigastric pain, however no alteration bowel habit, no vomiting, diarrhea and
hematemesis. Genitourinary system: There was no dysuria and hematuria, no polyuria,
polydypsia, urgency, swollen ankle or urinary incontinence. Her menarche when she was
13 years old with regular cycle. Musculoskeletal System: She had no muscle weakness,
arthralgia, bony pain, muscle stiffness and abnormal gait. Central Nervous System:
There were no syncope, and tremor, loss of sensory, diplopia, fit, paralysis, and speech
defect or body incoordinations.

PAST MEDICAL HISTORY:

She was diagnosed having systemic lupus erythematous (SLE) 2 years ago at 12
November 2007 when she first time admitted to hospital due to the same reason and still
under followed up at HoSHAS. She had no known other medical illnesses such as
diabetes mellitus, asthma, hypertension and ischemic heart disease.

PAST SURGICAL HISTORY:

She had no significant past surgical history.

DRUG/MEDICATION HISTORY:
She is on medication for SLE in tablet form Prednisolone 5 mg take once daily
and Ranitidine 150 mg once at night. She has good compliance. She had no known drug
allergies and she did not take any traditional medication.

FAMILY HISTORY:
Her sister also suffers from SLE but her sister’s condition is much worse than her.
Her mother has hypertension while her father has diabetes mellitus and hypotension. No
family history of other medical illnesses.

SOCIAL HISTORY:
She stayed with her family in single storey house at Felda Bukit Puchong which is
2 hours from the hospital. She is the 6th from 7 siblings. She is allergic towards seafood.

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She does not smoke and take alcohol. She is also not IVDU and had no sexual
promiscuity.

PHYSICAL EXAMINATION:
General Examination
On inspection, the patient is alert, conscious with GCS 15/15 but in pain at that
time lying on her bed using 1 pillow. There is branula on her right hand. The patient
looks well nourished but lethargic. Her vital signs were: Blood Pressure-110/70, Pulse
Rate-78 beats/ minute, good volume and regular rhythm, Respiratory Rate-20 breaths
per minute, Temperature-38 ˚C, SPO2-99%
She is fairly hydrated. There were no facies abnormalities, muscle wasting, scars
or any other abnormalities .There were also no signs of jaundice, pallor or cyanosis.
Hand: Warm, no excessive sweating, capillary filling time was less than 2 seconds, no
finger clubbing, no Dupuytren contracture, no palmar erythema, Eye: There are no signs
of pallor on the conjunctiva and jaundice on the sclera.
Mouth: No central cyanosis, no gum bleeding and hydration was fair.
Lower limb: No rashes or petechiae, no ankle edema.
Lymph nodes: No palpable lymph nodes detected

Specific physical examination

[Abdomen]
Inspection: Abdomen is symmetrical, scaphoid in shape and not distended. Umbilicus is
centrally located an inverted. Abdomen moves equally with respiration. There are no
scratch marks, visible veins, scars and obvious mass. Palpation: On light palpation, the
abdomen is soft, but is tenderness at epigastric region. No rebound tenderness, guarding,
rigidity and mass are founded. On deep palpation, no organomegaly detected.
Percussion: Abdominal resonance is present, no shifting dullness that indicates ascites.
Auscultation: Bowel sound is normal. Per Rectal examination,vaginal examination
and check for inguinal orifices is done to complete this examination.

Systemic examination

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[Cardiovascular system]
Inspection: Apex beat could no be seen. There were also no scars, precordial bulge and
extra pulsation observed. Palpation: The apex beat was present at left 5th intercostals
space at mid clavicular line with normal character. Parasternal heave and palpable thrill
were absent. Auscultation: The first and second heart sounds were present and normal.
There were no murmur and added heart sound.
[Respiratory system]
Inspection: The chest moved bilaterally symmetrical with respiration. The chest is
normal in shape, no kyphosis, no scoliosis and no lordosis. No dilated vein and no
surgical scars. No use of accessory muscles. Palpation: Chest expansion was equal in
both sides. Vocal fremitus were equal on both sides of the lung. Percussion: Equal
normal resonance on both sides of the lung on percussion. Auscultation: Air entry equal
bilaterally with vesicular breath sound. Vocal resonance was equal on both sides.

CASE SUMMARY:
20 year old Malay lady with known case of systemic lupus erythematous (SLE)
presented with sudden onset of fever associated with chills and rigor, chronic non-
productive cough for 1 month, lost of appetite and weight and proteinuria. On
examination, the abdomen is soft, tender at epigastric region, and no mass and
organomegaly detected, both heart sounds are heard and no murmur and the lung is clear
with vesicular breathing.

PROVISIONAL DIAGNOSIS:
Pyrexia of unknown origin (PUO) with underlying SLE and lupus nephritis
Reasons for: - prolonged fever for 1 month, underlying SLE, proteinuria

DIFFERENTIAL DIAGNOSIS:
1) Dengue fever (DF)
Reason for: fever, abdominal pain, retro orbital pain
Reason against: myalgia, arthralgia, persistent vomiting

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 2) Tuberculosis (TB)
Reason for: - cough more than 2 weeks, fever, lost of appetite and lost of
weight
Reason against: - Productive cough, night sweat

INVESTIGATIONS:
Date/Time Event Value: 16/09/09
Full Blood Count (FBC)
Objective: To look for leucocytosis, infection and anemia
Results: Haemoglobin-10.5 g/dL (12.0- 16.0) Platelet -141 K/uL (130-400)
White Blood Cells-3.9 K/uL ABNORMAL (4.8- 10.8)
Impression: Present of infection
Liver Function Tests (LFT)
Objective: To see any liver impairment
Results: Bilirubin, Total -8.00 umol/L (3.4 – 17.1) Alkaline Phosphatase-22 U/L
(20 - 95) Alanine Transaminase (SGPT)-14 U/L (0-30) Total protein- 70
g/dL (55 – 82) Albumin- 35 g/dL (27 – 46) Globulin – 35 g/dL (28 – 36) A/G
ratio- 1.0 (0.9 – 1.8)
Impression: Normal liver function
Renal Profile (RP)
Objective: To see any renal impairment
Results: Urea-3.4 mmol/L (2.5 – 7.5) Sodium-137 mmol/L (135-
148) Potassium- 3.8 mmol/L (3.3- 5.2) Creatinine- 59 umol/L
(44 - 80) Chloride-102 mmol/L (95 - 108) Urate- 285 mmol/L (120-420)
Impression: Normal renal function
Blood Urea & Serum Electrolyte (BUSE)
Objective: To detect any electrolyte imbalance
Results: Calcium- 2.0 Magnesium- 0.9 Phosphate- 1.6
Impression: No electrolyte imbalance
Urinalysis
Objective: To detect any RBCs, cast cells and protein in the urine

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Results: Urine FEME: Blood- 1+ Protein- 2+ Leukocytes- negative Urine Culture:
turbid, no growth Urine C&S: -ve 24-Hours urine protein: 0.53 g/day
ABNORMAL (0-0.15)
Impression: Proteinuria
Erythrocytes Sedimentation Rate (ESR)
Objective: Indication for inflammatory reaction
Results: 43 (<20mm/h)
Impression: Inflammatory reaction is present

MANAGEMENTS
She was given T. Prednisolone 40mg BD, IV Zinacef 750mg TDS, and T. Zantec
150mg BD since the day of admission. She was alert, conscious with vital signs: BP-
110/60, PR- 82, RR- 23 breaths/min and T- 38˚C when she was discharge on 20
September 2009 with prescribed medications such as T. Zantec 150mg BD, T.CaCO3
500mg BD, T.Prednisolone 40mg OD, T.Prednisolone 30mg OD, T.Prednisolone 20mg
OD. She had appointment as Medical Outpatient Department (MOPD) in 4 months to
refer to nephrologists for renal biopsy.

DISCUSSION
1. Source of infection which causes persistent fever is due to lupus nephritis with
underlying SLE. Evidence of proteinuria showed that there is increase
permeability in gromerular basement membrane which impaired kidney
function.
2. The epigastric pain may due to the side effect of the Prednisolone tablet which
can cause peptic ulcer while Ranitine is indicated to counteract with the side
effect of Prednisolone however it can cause hypersentivity reaction including
fever.
3. She develops photosensitive rashes on her face when expose to the sunlight
due to SLE so unlikely that she frequently go out and gets the infection from
the outside.

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