SYSTEMIC LUPUS ERYTHEMATOUS

  ๐—–๐—”๐—ฆ๐—˜ ๐—ฆ๐—–๐—˜๐—ก๐—”๐—ฅ๐—œ๐—ข :-

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

๐‡๐ˆ๐’๐“๐Ž๐‘๐˜ ๐Ž๐… ๐๐‘๐„๐’๐„๐๐“๐ˆ๐๐† ๐ˆ๐‹๐‹๐๐„๐’๐’ :-

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 
๐’Šน︎︎︎ H/o itching present over plaques 
๐’Šน︎︎︎ H/o photosensitivity 
๐’Šน︎︎︎ Swelling restrictions of movements persistent 
๐’Šน︎︎︎ C/o Wrist joint pain (+)
๐’Šน︎︎︎ C/o Metacarpo phalanges pain (+)
๐’Šน︎︎︎ C/o Interphalanges pain (+)
๐’Šน︎︎︎ C/o Tenderness present over wrist,mcp, Ip
๐’Šน︎︎︎ H/o fever & episode in last 8months
๐’Šน︎︎︎ Last episode 20days back
๐’Šน︎︎︎ Fever last for 1day relieved after taking medication
๐’Šน︎︎︎ H/o oral ulcer on hard palate since 10days 

๐‡๐ˆ๐’๐“๐Ž๐‘๐˜ ๐Ž๐… ๐๐€๐’๐“ ๐ˆ๐‹๐‹๐๐„๐’๐’ :-

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

๐๐„๐‘๐’๐Ž๐๐€๐‹ ๐‡๐ˆ๐’๐“๐Ž๐‘๐˜  :-

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

๐…๐€๐Œ๐ˆ๐‹๐˜ ๐‡๐ˆ๐’๐“๐Ž๐‘๐˜ :-

๐’Šน︎︎︎ No similar complaints in the family. 

๐๐‡๐˜๐’๐ˆ๐‚๐€๐‹ ๐‡๐ˆ๐’๐“๐Ž๐‘๐˜ :-

(1) ๐†๐„๐๐„๐‘๐€๐‹ ๐„๐—๐€๐Œ๐ˆ๐๐€๐“๐ˆ๐Ž๐ :-

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

๐’Šน︎︎︎ Vitals:-        Temp-Afebrile
                     Pulse rate -82/min
                     Respiratory rate-20/min
                     BP -100/70mmHg

(2) ๐’๐˜๐’๐“๐„๐Œ๐ˆ๐‚ ๐„๐—๐€๐Œ๐ˆ๐๐€๐“๐ˆ๐Ž๐ :-

๐’Šน︎︎︎ CVS -   Cardic sound S1&S2 heard
            Cardic mummers- No

๐’Šน︎︎︎ Respiratory system :-No Dyspnoea
                                      No Wheeze
                          Position of trachea -central
                         Breath sounds -vesicular(normal)
                          B/L air entry -Normal 

๐’Šน︎︎︎ Abdomen :-  Shape of abdomen - scaphoid 
                       Tenderness-No
                   Palpable masses- No organomegaly 
                        Liver- Not palpable 
                        Spleen- not palpable 
                        Bowel sounds - yes 
                        Hernial orifices- Normal
                       
๐’Šน︎︎︎ 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

๐ˆ๐๐•๐„๐’๐“๐ˆ๐†๐€๐“๐ˆ๐Ž๐๐’ :-
๐’Šน︎︎︎ USG :-
-small shrunken Right kidney with grade-3     RPD changes 
 - Grade-2 fatty liver with mild hepatomegaly
 - Right renal cortical cyst 
 
๐’Šน︎︎︎ 2D ECHO :-
 - Good LV systolic function 

 ๐’Šน︎︎︎ HAEMOGRAM -

๐๐‘๐Ž๐•๐ˆ๐’๐ˆ๐Ž๐๐€๐‹ ๐ƒ๐ˆ๐€๐†๐๐Ž๐’๐ˆ๐’ :-
      
 ๐™Ž๐™”๐™Ž๐™๐™€๐™ˆ๐™„๐˜พ ๐™‡๐™๐™‹๐™๐™Ž ๐™€๐™๐™”๐™๐™ƒ๐™€๐™ˆ๐˜ผ๐™๐™Š๐™๐™Ž 

๐“๐‘๐„๐€๐“๐„๐Œ๐„๐๐“ :- 

- 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

 ๐€๐ƒ๐•๐ˆ๐‚๐„ :- 

No active intervention Needed from nephrology 

 ๐…๐Ž๐‹๐‹๐Ž๐– ๐”๐ :-
 
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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This is an 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. 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. Patient and his/her attenders have been informed and their consent has been taken. A 65 yr old female was brought to the casualty with  complaints of  • Difficulty in moving upper limbs and lower limbs since 3
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