SYSTEMIC LUPUS ERYTHEMATOUS

  𝗖𝗔đ—Ļ𝗘 đ—Ļ𝗖𝗘𝗡𝗔đ—Ĩ𝗜đ—ĸ :-

A  35yr old male came to causality with chief complaints of itching skin lesions all over body since 8months 

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐑𝐄𝐒𝐄𝐍𝐓𝐈𝐍𝐆 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

Patient was apparently asymptomatic 8months ago the he developed small papulesbover cheek after which it transformed into erythematous scaly plaque first on nose cheek then over entire face, neck ,back ,hand and to  legs 
𒊹ī¸Žī¸Žī¸Ž H/o itching present over plaques 
𒊹ī¸Žī¸Žī¸Ž H/o photosensitivity 
𒊹ī¸Žī¸Žī¸Ž Swelling restrictions of movements persistent 
𒊹ī¸Žī¸Žī¸Ž C/o Wrist joint pain (+)
𒊹ī¸Žī¸Žī¸Ž C/o Metacarpo phalanges pain (+)
𒊹ī¸Žī¸Žī¸Ž C/o Interphalanges pain (+)
𒊹ī¸Žī¸Žī¸Ž C/o Tenderness present over wrist,mcp, Ip
𒊹ī¸Žī¸Žī¸Ž H/o fever & episode in last 8months
𒊹ī¸Žī¸Žī¸Ž Last episode 20days back
𒊹ī¸Žī¸Žī¸Ž Fever last for 1day relieved after taking medication
𒊹ī¸Žī¸Žī¸Ž H/o oral ulcer on hard palate since 10days 

𝐇𝐈𝐒𝐓𝐎𝐑𝐘 𝐎𝐅 𝐏𝐀𝐒𝐓 𝐈𝐋𝐋𝐍𝐄𝐒𝐒 :-

𒊹ī¸Žī¸Žī¸Ž H/o CVA  left Up & Ll weakness &slured speech  10 years back
𒊹ī¸Žī¸Žī¸Ž H/o Appendectomy 8year back 
𒊹ī¸Žī¸Žī¸Ž N/k/c/o DM, HTN,TB,Epilepsy,CAD, 
𒊹ī¸Žī¸Žī¸Ž Used Ayurvedic medication 2 months back for 15days

𝐏𝐄𝐑𝐒𝐎𝐍𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘  :-

𒊹ī¸Žī¸Žī¸Ž Married
𒊹ī¸Žī¸Žī¸Ž Occupation -driver
𒊹ī¸Žī¸Žī¸Ž Appetite-decrease 
𒊹ī¸Žī¸Žī¸Ž Mixed diet 
𒊹ī¸Žī¸Žī¸Ž Bowel- Regular 
𒊹ī¸Žī¸Žī¸Ž Micturition-normal
𒊹ī¸Žī¸Žī¸Ž Habit/addiction 
𒊹ī¸Žī¸Žī¸Ž Alcohol-toddy dinner since 20yr 
𒊹ī¸Žī¸Žī¸Ž Occasionall alcoholic
𒊹ī¸Žī¸Žī¸Ž BD since 25year (15 per day)

𝐅𝐀𝐌𝐈𝐋𝐘 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

𒊹ī¸Žī¸Žī¸Ž No similar complaints in the family. 

𝐏𝐇𝐘𝐒𝐈𝐂𝐀𝐋 𝐇𝐈𝐒𝐓𝐎𝐑𝐘 :-

(1) 𝐆𝐄𝐍𝐄𝐑𝐀𝐋 𝐄𝐗𝐀𝐌𝐈𝐍𝐀𝐓𝐈𝐎𝐍 :-

Height-                                   Weight-
                       
Pallor-absent 
Icterus- absent                             Clubbing-absent
Cynosis- absent                            Oedema -absent 
Lymphadenopathy-absent           
 No Malnutrition 
No Dehydration 

𒊹ī¸Žī¸Žī¸Ž Vitals:-        Temp-Afebrile
                     Pulse rate -82/min
                     Respiratory rate-20/min
                     BP -100/70mmHg

(2) 𝐒𝐘𝐒𝐓𝐄𝐌𝐈𝐂 𝐄𝐗𝐀𝐌𝐈𝐍𝐀𝐓𝐈𝐎𝐍 :-

𒊹ī¸Žī¸Žī¸Ž CVS -   Cardic sound S1&S2 heard
            Cardic mummers- No

𒊹ī¸Žī¸Žī¸Ž Respiratory system :-No Dyspnoea
                                      No Wheeze
                          Position of trachea -central
                         Breath sounds -vesicular(normal)
                          B/L air entry -Normal 

𒊹ī¸Žī¸Žī¸Ž Abdomen :-  Shape of abdomen - scaphoid 
                       Tenderness-No
                   Palpable masses- No organomegaly 
                        Liver- Not palpable 
                        Spleen- not palpable 
                        Bowel sounds - yes 
                        Hernial orifices- Normal
                       
𒊹ī¸Žī¸Žī¸Ž CNS - level of consciousness -conscious 
              Speech- Normal
              No Signs of meningical irritation ( neck stiffness, kernigs signs)
                Cranial  nerves-normal
                 Motor system- normal
                  Sensory system-normal 
                  Glasgrow scale

𝐈𝐍𝐕𝐄𝐒𝐓𝐈𝐆𝐀𝐓𝐈𝐎𝐍𝐒 :-
𒊹ī¸Žī¸Žī¸Ž USG :-
-small shrunken Right kidney with grade-3     RPD changes 
 - Grade-2 fatty liver with mild hepatomegaly
 - Right renal cortical cyst 
 
𒊹ī¸Žī¸Žī¸Ž 2D ECHO :-
 - Good LV systolic function 

 đ’Ššī¸Žī¸Žī¸Ž HAEMOGRAM -

𝐏𝐑𝐎𝐕𝐈𝐒𝐈𝐎𝐍𝐀𝐋 𝐃𝐈𝐀𝐆𝐍𝐎𝐒𝐈𝐒 :-
      
 đ™Žđ™”đ™Žđ™đ™€đ™ˆđ™„đ˜ž 𝙇𝙐𝙋𝙐𝙎 𝙀𝙍𝙔𝙏𝙃𝙀𝙈đ˜ŧ𝙏𝙊𝙐𝙎 

𝐓𝐑𝐄𝐀𝐓𝐄𝐌𝐄𝐍𝐓 :- 

- MUCOPAIN GEL-  thrice daily
- T. PCM-650 - thrice daily
- T.BENFOMET PLUS- once daily
- T.PREGABALIN- once daily
- T.BACLOFENX-L- once daily
- T.LORAZEPAM - once daily
- T.NICOTINE GUMS- twice daily
- T. HCQ-200mg/BD

 đ€đƒđ•đˆđ‚đ„ :- 

No active intervention Needed from nephrology 

 đ…đŽđ‹đ‹đŽđ– 𝐔𝐏 :-
 
5/4/23  8:00a.m
   35/M
S- Fever spike - 100.2F
      chronic alcoholic, smoker. 
O-  O/E  Pt is c/c/c
               PR-92 bpm
               Temp- 100.2F
               BP- 110/80 mmHg
               CVS- S1 S2 heard
                          no murmurs 
               RS- B/L AE+ ;NVBS
               P/A- soft, non tender
               CNS- NAD
A- ? SLE
     ? Lupus nephritis 
        with CKD Stage-2 
P- 1) Sunsos Aquagel SPF50 L/A
     2) Mucopain gel L/A TID
     3) Tab. PCM 650mg PO/TID
     4) Tab. Ecospirin-AV 75/20mg PO/HS
     5) Tab. Benfomet Plus PO/OD


  6/4/23   8:00a.m
   
35/M
S-  Fever spike 
      Arthralgia
      B/L hand MCP
O-  O/E 
       pt is c/c/c
      PR- 84bpm
      temp- 99F
       BP- 110/80mmHg
       cvs- S1 ,S2 heard 
                No murmur 
        RS- B/L AE(+)
                NVBS 
        P/A-soft non tender
        CNS - NAD
  A- ?SLE
        ? lupus nephritis 
          with CKD Stage- 2
          Bicytopinea 
         k/c/o CVA 10 years back
  P- 1) Sunsos Aquagel SPF50 L/A
     2) Mucopain gel L/A TID
     3) Tab. PCM 650mg PO/TID
     4)Tab. Benfomet Plus PO/OD

7/4/23     8:00am
 
S- C/o giddiness-positional variations
     No fever spikes
O-  O/E  pt is c/c/c
       PR- 82bpm
       RR- 24cpm
       Temp-97.4F
        BP- 120/80mmHg
        GRBS- 98mg/dl
        CVS - S1,S2 heard 
                    No murmur
         RS-B/L AE (+)
                NVBS    
         P/A -soft non tender
         CNS - NAD
A-  ?SLE
       ? lupus nephritis 
          with CKD Stage- 2
          Bicytopinea 
         k/c/o CVA 10 years back
 
P- 1) Sunsos Aquagel SPF50 L/A
     2) Mucopain gel L/A TID
     3) Tab. PCM 650mg PO/TID
     4)Tab. Benfomet Plus PO/OD
     5)Tab.Baclofen XL- 20mg
     6)Tab. Pregabalin-75mg PO/H/S
     7) Nicotine Gums-2mg
     8)Temperature monitoring 4th hourly
     9)BP,RR,PR monitoring 4th hourly  
    10)Tab.HCQ -200mg PO/BD

8/4/23. 8:00am
 
35/M
S - Burning sensation in both the palms
      ( on the areas of plaques)
     Stools passed 
O- O/E pt is c/c/c
     PR- 82bpm
       RR- 26cpm
       Temp-98.7F
        BP- 120/80mmHg
        GRBS- 92mg/ dl
        CVS - S1,S2 heard 
                    No murmur
         RS-B/L AE (+)
                NVBS    
         P/A -soft non tender
         CNS - NAD
      
A-  ?SLE
       ? lupus nephritis 
          with CKD Stage- 2
          Bicytopinea 
         k/c/o CVA 10 years back

P- 1) Sunsos Aquagel SPF50 L/A
     2) Mucopain gel L/A TID
     3) Tab. PCM 650mg PO/TID
     4)Tab. Benfomet Plus PO/OD
     5)Tab.Baclofen XL- 20mg
     6)Tab. Pregabalin-75mg PO/H/S
     7) Nicotine Gums-2mg
     8)Temperature monitoring 4th hourly
     9)BP,RR,PR monitoring 4th hourly  
    10)Tab.HCQ -200mg PO/BD

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