A 35 year old male with SLE
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Chief complaint :
Patients 35yr old male came to causality with chief complaint of itching skin lesions all over body since 8months
History of present 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
H/o itching present over plaques
H/o photosensitivity
Swelling restrictions of movements persistent
Complaints of joint pains
Pain in Wrist joint- present
pain in Metacarpo phalanges -present
Pain in Interphalanges-present
Tenderness present over wrist, mcp, Ip
H/o fever & episode in last 8months
Last episode 20days back
Fever last for 1day relieved after taking medication
H/o oral ulcer on hard palate since 10days
History past illness
H/o CVA left Up & Ll weakness &slured speech 10years back
H/o Appendectomy 8year back
N/k/c/o DM, HTN,TB,Epilepsy,CAD, used Ayurvedic medication 2 months back for 15days
Personal History :
Married
Occupation -driver
Appetite-decrease
Mixed diet
Bowel- Regular
Micturition-normal
Habit/addiction :-
Alcohol-toddy dinner since 20yr
Occasionall alcoholic
BD since 25year (15 per day)
Family History:
No similar complaints in the family.
Physical History:
Height- Weight-
Pallor-absent
Icterus- absent Clubbing-absent
Cynosis- absent Oedema -absent
Lymphadenopathy-absent
No Malnutrition
No Dehydration
Vitals:- Temp-Afebrile
Pulse rate -82/min
Respiratory rate-20/min
BP -100/70mmHg
Systemic Examination:
CVS - Cardic sound S1&S2 heard
Cardic mummers- No
Respiratory system :-No Dyspnoea
No Wheeze
Position of trachea -central
Breath sounds -vesicular(normal)
B/L air entry -Normal
Abdomen :- Shape of abdomen - scaphoid
Tenderness-No
Palpable masses- No organomegaly
Liver- Not palpable
Spleen- not palpable
Bowel sounds - yes
Hernial orifices- Normal
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:
USG- small shrunken Right kidney with grade-3 RPD Changes
- Grade-2 fatty liver with mild hepatomegaly
Right renal cortical cyst
2D ECHO- Good systolic function
Haemogram -
Provisional Diagnosis:
Systemic lupus erythematous
Treatment:-
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
ADVICE:-
No active intervention Needed from nephrology
Follow 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