fever projr sle 30/F

 sle ; 

date of admission 25/4/2024

LAMA 

date of discharge 26/4/2024

Diagnosis

K/C/O SYSTEMIC LUPUS ERYTHAMATOUSUS FLARE UP SECONDARY TO NON COMPLIANCE TO DRUG WITH LUPUS NEPHRITIS WITH ADJUSTMENT DISORDER

Case History and Clinical Findings

C/O OF FEVER SINCE 10 DAYS

C/O OF COUGH SINCE 10 DAYS

PATIENT WAS APPARENTLY ASYMPTOMATIC 10 DAYS BACK ,THEN DEVELOPED FEVER ,SUDDEN IN ONSET ,CONTINUES TYPE ,A/W WITH CHILLS ,H/O COUGH ,PRODUCTIVE TYPE ,WHITISH SPUTUM SINCE 1 DAY .H/O OF NAUSEA PRESENT ,H/O OF DYSPHAGIA WITH STOMATITIS AND GLOSSITIS

NO H/O OF SHORTNESS OF BREATH ,CHEST PAIN ,VOMITING ,LOSS OF CONSIOUSNESS , NO H/O OF PALPITATIONS ,DIZZINESS ,HEADCHE

GENERAL EXAMINATION

PATIENT IS C/C/C

NO PALLOR ,ICTERUS, CYANOSIS ,CLUBBING ,LYMPHADENOPATHY ,OEDEMA OF FEET

VITALS

BP 100MMHG

PR 86 BPM

RR 23 CPM

TEMPERATURE 98.8 F

STSTEMIC EXAMINATION

RS ; BAE PRESENT , NVBS

CVS ;S1 ,S2 HEARED

CNS ; NFND

PA ; SOFT NON TENDER

REFERRAL DONE BY PSYCHIATRY I/V/O ADJUSTMENT DISORDER

ADVICE-

TAB MIRTAZEPINE 7.5 MG 0-0-1

REFERRAL DONE BY OPTHALMOLOGY I/V/O VAWSCULITIS

ADVICE-

FUNDUS FLUROSCEIN ANGIOGRAPHY AND OCT

REFERRAL DONE BY ENT I/V/O ORAL CANDIDIASIS

ADVICE-

2%BETADINE GARGLES [DILUTED] 3-4 TIMES /DAY X 5 DAYS

COURSE IN HOSPITAL -

30 YR OLD FEMALE CAME WITH COMPLAINTS OF FEVER SINCE 10 DAYS .ON DAY OF ADMISSION PT WAS IRRITABLE.ON EVALUATION IN PREVIOUS ADMISSION PATIENT WAS FOUND TO HAVE ANTIBODIES DETECTED AGAINST smD1 ANTIGEN WITH AN INDEX 5.96 AND INTERPRETATION (+++)U1-snRNP ANTIGEN WITH INDEX 4.80 AND INTERPRETATION (+++) NUCLEOSOME ANTIGEN WITH INDEX 1.57 AND INTERPRETATION (+)KU ANTIGEN WITH AN INDEX 1.00 AND INTERPRETATION IS BORDER POSITIVE IN PREVIOUS ADMISSION.PATIENT HAD CLINICAL FEATURES OF SLE FOR WHICH PREDNISOLONE 40 MG WAS STARTED BUT PATIENT WAS NON COMPLIANT TO DRUGS.SO SHE WAS AGAIN STARTED WITH PREDNISOLONE.OPTHALMOLOGYBREFERRAL WAS TAKEN I/V/O DOV NOTICED VASCULITIS,SO MRI BRIAN WAS DONE I/V/O VASCULITIS BUT NO ABNORMALITY WAS DETECTED PSYCHIATRY OPINION WAS TAKEN I/V/O IRRITABLE BEHAVIOUR FOR WHICH APPROPRIATE TREATMENT WAS GIVEN . PATIENT WAS IMPROVING CLINICALLY BUT NEEDS FURTHER EVALUATION FOR ?LUPUS NEPHRITIS.BIOPSY WAS DONE ON 2/05/2024 , REPORTS ARE YET TO COME ,BUT PATIENT AND PATIENT ATTENDERS ARE NOT WILLING TO STAY AND WANT TO LEAVE AGAINST MEDICAL ADVISE .

Investigation

NameValueRangeNameValueRangeLIVER FUNCTION TEST (LFT) 25-04-2024 06:30:PM

Total Bilurubin

0.53 mg/dl1-0 mg/dl

Direct Bilurubin

0.19 mg/dl0.2-0.0 mg/dl

SGOT(AST)

203 IU/L31-0 IU/L

SGPT(ALT)

74 IU/L34-0 IU/L

ALKALINE PHOSPHATASE

143 IU/L98-42 IU/L

TOTAL PROTEINS

7.6 gm/dl8.3-6.4 gm/dl

ALBUMIN

3.0 gm/dl5.2-3.5 gm/dl

A/G RATIO

0.67

BLOOD UREA 

25-04-2024 06:30:PM38 mg/dl42-12 mg/dl

SERUM CREATININE

25-04-2024 06:30:PM0.8 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) 25-04-2024 06:30:PM

SODIUM

132 mmol/L145-136 mmol/L

POTASSIUM

3.9 mmol/L5.1-3.5 mmol/L

CHLORIDE

102 mmol/L98-107 mmol/L

HBsAg-RAPID25-04-2024 06:30:PM

Negative

Anti HCV Antibodies - RAPID

25-04-2024 06:30:PMNon Reactive COMPLETE BLOOD PICTURE (CBP) 26-04-2024 12:27:AM

HAEMOGLOBIN

9.5 gm/dl15.0-12.0 gm/dl

TOTAL COUNT

3000 cells/cumm10000-4000 cells/cumm

NEUTROPHILS

80 %80-40 %

LYMPHOCYTES

17 %40-20 %

EOSINOPHILS

00 %6-1 %

MONOCYTES

03 %10-2 %

BASOPHILS

00 %2-0 %

PLATELET COUNT

1.52SMEARNormocytic normochromic anemia with leucopeniaCOMPLETE URINE EXAMINATION (CUE) 27-04-2024 01:05:PM

COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY

1.010

ALBUMIN

++++

SUGAR

Nil

BILE SALTS

Nil

BILE PIGMENTS

Nil

PUS CELLS

3-4

EPITHELIAL CELLS

2-3

RED BLOOD CELLS

Nil

CRYSTALS

Nil

CASTS

Nil

AMORPHOUS DEPOSITS

Absent

OTHERS

NilCOMPLETE BLOOD PICTURE (CBP) 27-04-2024 11:41:PM

HAEMOGLOBIN

9.1 gm/dl15.0-12.0 gm/dl

TOTAL COUNT

5000 cells/cumm10000-4000 cells/cumm

NEUTROPHILS

80 %80-40 %

LYMPHOCYTES

15 %40-20 %

EOSINOPHILS

00 %6-1 %

MONOCYTES

05 %10-2 %

BASOPHILS

00 %2-0 %

PLATELET COUNT

1.2SMEARNormocytic normochromic anemia with mild thrombocytopenia

HEMOGRAM ON 25/4/24

HEMOGLOBIN-8.6

TC-3000

RBC-3.6

PLATELETS - 1.7

ON 26/4/24

HB-9.5

TC-3000

PLATELET -1.52

ON 27/4/24

HB-10.5

TC-4000

PLATELET-1.20

RBC-4.36

ON 28/4/24

HB-9.1

TC-5000

PLATELET-1.2

ON 29/4/24

HB-9.8

TC-4000

PLATELET-1.5

IMPRESSION:MICROCYTIC HYPOCHROMIC ANEMIA

30/4/24

HB-11.4

TC-3000

PLATELETS-80000

IMPRESSION:NORMOCYTIC NORMOCHROMIC WITH FER MICROCYTES

HEMOGRAM ON 30/4/24

HEMOGLOBIN-8.9

TC-4000

RBC-3.65

PLATELETS - 80000

HEMOGRAM ON 1/5/24

HEMOGLOBIN-8.6

TC-4000

RBC-3.65

PLATELETS - 1.4

HEMOGRAM ON 2/5/24

HEMOGLOBIN-9.5

TC-4000

RBC-4.04

PLATELETS - 1.4

ESR ON 28/4/24 - 62

RFT ON 30/4/24

UREA - 44

CREAT - 0.7

SODIUM - 135

POTASSIUM - 4.7

CHLORIDE - 102

IONISED CALCIUM - 1.12

MRI BRAIN ON 27/4/24- NO ABNORMALITY DETECTED

STOOL FOR C/S ON 26/4/24

NO OVA OR CYSTS SEEN

NO PATHOGENIC ORGANISM ISOLATED

URINE FOR C/S ON 29/4/24

0-1 PUS CELLS SEEN

POLYMICROBIAL FLORA GROWN

USG ON 26/4/24

NO SONOLOGICAL ABNORMALITY DETECTED APART FROM B/L TINY RENAL CALCULI

24H URINE PROTEIN TO CREATINE RATIO - 0.30

24 HR PROTEIN - 242

24 HR CREATININE - 0.8

URINE VOL - 800 ML

RENAL BIOPSY WAS DONE ON 3/05/24 REPORTS ARE YET TO COME

REVIEW USG WAS DONE ON 4/4/24 I/V/O ANY COLLECTIONS POST BIOPSY -

NO COLLECTIONS WERE NOTES IN PERI RENAL REGION

Treatment Given(Enter only Generic Name)

IVF NS/RL @ 75ML/HR

INJ NEOMOL 1 GM IV BD

INJ PAN 40 MG IV OD

INJ ZOFER 4 MG IV SOS

INJ OPTINEURON 1 AMP IN 100ML NS

TAB FLUCONAZOLE 150 MG OD PO X 1 DAY

INJ MONOCEF 1 GM IV BD

TAB . WYSOLONE 40 MG PO BD X 9 DAYS

CANDIDA MOUTH PAINT L/A TID FOR 1 DAY

TAB .PCM 650 MG PO QID 6 DAYS

TAB .MIRTAZIPINE 7.5 MG PO HS

TAB CLONAZEPAM 0.25 MG IF PATIENT IS ANXIOUS AND /IRRITABLE/HELPLESS

Advice at Discharge

LAMA NOTES -

PATIENT AND PATIENT ATTENDERS HAVE BEEN EXPLAINED ABOUT THE CONDITION OF THE PATIENT THAT IS, SYSTEMIC LUPUS ERYTHEMATOUS WITH LUPUS NEPHRITIS WITH ADJUSTMENT DISORDER AND ITS RISK AND COMPLICATIONS ASSOCIATED WITH IT IN THEIR OWN UNDERSTANDABLE LANGUAGE[TELUGU]. PATIENT AND PATIENT ATTENDERS ARE REFUSING FOR FURTHER INVESTIGATIONS AND TREATMENT INSPITE OF EXPLAINING THE RISK AND COMPLICATIONS, PATIENT AND PATIENT ATTENDERS WANT TO LEAVE AGAINST MEDICAL ADVICE.

DOCTORS, STAFF, MANAGEMENT ARE NOT RESPONSIBLE FOR ANY UNTOWARD EFFECTS TO THE PATIENT INCLUDING CARDIAC ARREST.