fever projr sle 36/M 15122

 sle - 202315122

Diagnosis


1.?SLE

2.LUPUS NEPHRITIS WITH CKD STAGE-II

3.BICYTOPENIA -THROMBOCYTOPENIA AND LEUKOPENIA

4.K/C/O CVA 10 YEARS BACK(?RIGHT MCA)

Case History and Clinical Findings

C/O ITCHY SKIN LESIONS ALL OVER BODY SINCE 8 MONTHS

HOPI:

PATIENT WAS APPARENTLY ALRIGHT 8 MONTHS BACK THEN HE DEVELOPED SMALL PAPULES OVER THE CHEEK AFTER WHICH IT TRANSFORMED INTO ERYTHEMATOUS SCALY PLAQUES FIRST ON THE NOSE CHEEK THEN OVER THE ENTIRE FACE ,NECK ,BACK,HANDS ,LEGS .H/O ITCHING PRESENT OVER THE PLAQUES . H/O PHOTOSENSITIVITY .

C/O JOINT PAINS ,WRIST PAIN MCP JOINTS ,IP.

TENDERNESS IN WRIST JOINT,MCP,IP.

H/O FEVER 4 EPISODES IN LAST 8MONTHS, LAST EPISODE 20 DAYS BACK .FEVER LAST FOR 1 DAY RELIEVED AFTER TAKING MEDICATION . H/O ORAL ULCER ON HARD PALATE SINCE 10 DAYS .

NO DECRECED OR INCRESED OUTPUT

PAST HISTORY-


H/O CVA -LEF UL AND LL WEAKNESS ANS SLURRED SPEECH 10 YEARS BACK USED MEDICATION ONLY FOR 1 MONTH.

H/O APPENDECTOMY 8 YEARS BACK .

N/K/C/O DM ,HTN,TB,EPILEPSY,CAD .

USED AYURVEDIC MEDICATION 1 MONTH BACK FOR 15 DAYS

PERSONAL HISTORY:

TAKES MIXED DIET, WITH DECREASED APPETITE

HAS REGULAR BOWEL AND BLADDER HABITS

ADDICTIONS- TODDY DRINKER SINCE 20 YEARS, 2 LITRES DAILY, OCCASIONAL ALCOHOLIC

BEEDI SINCE 25 YEARS .

O/E:

PATIENT IS C/C/C

NO SIGNS OF PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

EDEMA PRESENT UPTO KNEE-PITTING TYPE OF EDEMA

VITALS

TEMP:96.8F

PR:80 BPM

RR:20 CPM

BP:110/80 MM HG

GRBS: 92 MG/DL

CVS: S1 S2 HEARD

RS: BAE PRESENT

P/A: SOFT, NON TENDER

CNS: NFND

EXAMINATION OF TEETH AND ORAL CAVITY: ORAL ULCER ON HARD PALATE

PSYCHIATRY REFERRAL DONE ON 06/04/23 I/V/O ALCHOHOL DEPENDANCE SYNDROME

ADVICED-

T. PREGABALIN 75MG PO OD

T. BACLOFEN XL 20MG PO OD

T. BENFOTHIAMINE 100MG PO OD

NICOTINE GUMS 2MG 1-1 AND SOS

NEHPROLOGY REFERRAL DONE ON 06/04/23 I/V/O CKD STAGE-II WITH SMALL KIDNEY

ADVICE- NO ACTIVE INTERVENTION NEEDED


OPHTHALMOLOGY REFERRAL DONE ON 07/04/23- NORMAL ANTERIOR SEGMEWNT AND FUNDUS

Investigation

USG-

SMALL SHRUKEN RT. KIDNEY WITH GRADE 3 RPD CHANGES .

GRADE 2 FATTY LIVER WITH MILD HEPATOMEGALY.

RT. RENAL CORTICAL CYST.

2D ECHO-

EF- 67%

NO RWMA.

GOOD LV SYSTOLIC FUNCTION

HAEMOGRAM-

HB-13.9GM/DL

WBC-3,200 CELLS/CUMM

RBC -4.19 MILLIONS/CUMM

PLATELET COUNT-1.3 LAKHS/CUMM

PCV- 40

Treatment Given(Enter only Generic Name)

1.SUNCROS AQUAGEL SPF 50 L/A

2.MUCOPAIN GEL L/A TID

3.T. PARACETAMOL 650 PO/TID

4.T. ECOSPORIN- AV 75 mg PO/HS

5. T. BENFORMET PLUS PO/OD

6.T. BACLOFEN X -L 20mg OD

7. NICOTINE GUMS 2mg BD/SOS

8.T. PREGABALIN 75mg OD

9.T. HCQ 200mg PO/BD

Advice at Discharge

1. SUNCROS AQUAGEL SPF 50 L/A

2. MUCOPAIN GEL L/A TID

3. T.PARACETAMOL 650 PO/TID

4. T.BENFORMET PLUS PO/OD

5. T.BACLOFEN X -L 20mg OD


6. NICOTINE GUMS 2mg BD/SOS

7. T. PREGABALIN 75mg OD

8. T.HCQ 200mg PO/BD

9. T. PREGABALIN 75MG PO OD X 1 WEEK

10. T. BACLOFEN XL 20MG PO ODX 1 WEEK

11. T. BENFOTHIAMINE 100MG PO ODX 1 WEEK

12. NICOTINE GUMS 2MG 1-1 AND SOSX 1 WEEK




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