25F WITH FEVER SINCE 3 MONTHS
This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.
On 18/10
This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.
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.
25 year female got married 8 years ago 2nd degree consagunious marraige
1st son -3 years after marraige
During her second pregnancy which is 6 years after marraige she had hyperpigmented lesion over her cheeck initially small in size which latter progressed to butterfly shaped lesion over both cheecks
Since 3 months she is having high grade fever and went to rmp and used medication and she also has abdominal pain for which she was admitted in our hospital on 26/8/23 and treated as acute gastritis
After discharge she developed skin lesions over b/l lower limbs associated with itching which later progressed to painful pus filled ulcers over b/l lower limbs ,over left elbow and lumbosacral region
Since 3 months she has hairfall and multiple joint pains elbow,wrist joint,interphalengeal joints ,knee joint
5days back she had 2 episodes of generalized tonic seizures for about 2 minutes with uprolling of eyes ,with lip bite ,and no involuntary micturition or defecation ,no frothing
No previous abortion history
Since 3 months she has ammenorhea
Patient is conscious , coherent , cooperative
Pallor present
No signs of icterus , cyanosis , clubbing , lymphadenopathy, edema
Vitals:
Temp - 101.5 F
PR - 65 bpm
BP - 90/60 mmhg
RR - 20cpm
CVS - S1, S2 heard, no murmers
RS - BLAE present , NVBS
P/A - soft , non tender, no organomegaly
CNS - no FND
INVESTIGATIONS:
Urea - 20
Creatine - 0.7
Na - 124 Meq / Mol
K - 3.3 Meq/Mol
Cl- 98
Ionized calcium- 1.10
LFT:
TB- 1.30
DB - 0.40
AST- 80
ALT - 20
ALP- 667
TP- 5.8
ALB- 1.83
A/G- 0.46
Urinary chloride - 138
Urinary potassium - 12.4
Urine sodium - 84
Serology- negative
Upt- negative
Chest X ray:
USG:
2D echo -
On 12/10
On 13/10
On 14/10
On 16/10
Skin biopsy HPE report :
Diagnosis :
Systemic lupus erythematosis
Treatment:
1.inj.neomol IV/ SOS
2. IV fluids NS,RL
3. inj.MONOCEF 1gm IV/BD
4.inj.PAN 40mg IV/OD
5. T.prednisolone 30mg then tapered to 20mg
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