fever projr sle 30/F lupus nephritis 202305865

 sle - 20230209367

Diagnosis



ACUTE KIDNEY INJURY ON CHRONIC KIDNEY DISEASE [LUPUS NEPHRITIS STAGE 1V/V] SECONDARY TO ACUTE GASTROENTERITIS [ RESOLVED ]

WITH HYPERKALEMIA [ RESOLVED ]

WITH ? ANEMIA OF CHRONIC INFLAMMATION WITH ? ANEMIA INDUCED HEART FAILURE WITH ? ACUTE PULMONARY EDEMA [RESOLVED]

Case History and Clinical Findings

CHIEF COMPLAINTS :

C/O VOMITING AND LOOSE STOOLS SINCE 3 DAYS

HOPI :

PT WAS APPRENTLY ASYMPTOMATIC 3 DAYS AGO THEN SHE DEVELOPED LOOSE STOOLS 3-4 EPISODES / DAY , WATERY CONSISTENCY , NOT ASSOCIATED WITH FEVER , PAIN ABDOMEN

C/O VOMITINGS SINCE 3 DAYS 2-3 EPISODES PER DAY CONTAINED FOOD PARTICLES INITIALLY THEN HAD YELLOWISH COLOR VOMITINGS , NON FOUL SMELLING , NON BLOOD STAINED


K/C/O SLE WITH LUPUS NEPHRITIS SINCE 2 MONTHS AND IS ON TAB HCQ 200MG

IS ON RABEPRAZOLE + DOMPRIDONE 7AM

T.OROFER XT PO/OD 8AM

T.SHELCAL 500MG PO/OD 8AM

T.SODIUMBICARBONATE 500MG PO/BD 2PM AND 8PM

T.NICARDIA 20MG PO/TID 8AM-2PM-8PM

T.NEPHROSAVE PO/OD 2PM

PROBIOTICS

N/K/C/O DM , ASTHMA , EPILEPSY , CAD , CVA , THYROID DISORDERS

K/C/O HTN SINCE 3 MONTHS

NO PAST SURGICAL HISTORY

MENSTRUAL CYCLE :

IRREGULAR SINCE 2 MONTHS

LMP - 25TH DECEMBER 2022

O/E:

PT. IS C/C/C

NO PALLOR,ICTERUS,CYANOSIS,CLUBBING,LYMPHEDENOPATHY,PEDAL EDEMA

TEMP : 98.2F

BP-180/110MMHG

PR-131BPM

RR-24CPM

RBS-118MG/DL

CVS-S1S2+,NO MURMURS

RA-BAE+,NVBS

P/A-SOFT, TENDERNESS AROUND UMBLICUS , BOWEL SOUNDS HEARD

CNS-NO FND

OPTHALMOLOGY OPINION WAS TAKEN I/V/O HYPERTENSIVE RETINOPATHY CHANGES AND NO HYPERTENSIVE CHANGES WERE NOTED

GYNECOLOGY OPINION WAS TAKEN I/V/O AMENORRHOEA SINCE 3 MONTHS AND

ENT OPINION WAS TAKEN I/V/O DYSPHAGIA AND WAS DIAGNOSED ODYNOPHAGIA SECONDARY TO GASTRITIS

BLOOD TRANSFUSION OF 1 PRBC WAS DONE ON 13/2/23 IV/O LOW HEMOGLOBIN

NEPHROLOGY OPINION WAS TAKEN I/V/O OF RASIED SERUM CREATINE AND UREA LEVELS AND WAS ADVICED HEMODIALYSIS


HEMODIALYSIS WAS DONE ON 16/2/23 AND 17/2/23

Investigation

USG ABDOMEN AND PELVIS ON 06/2/23

B/L RAISED ECHOGENECITY IN BOTH KIDNEYS

MILD ASCITIS

USG ABDOMEN AND PELVIS ON 9/2/23

GB WALL EDEMA NOTED MEASURING 8MM

MILD RIGHT PLEURAL EFFUSION , MINIMAL LEFT PLEURAL EFFUSION

IVC DIAMETER MAX 18MM MIN 16MM

DILATED HEPATIC VEINS NOTED

MINIMAL PERICARDIAL EFFUSION

FEATURES SUGGESTIVE OF SEROSITIS

HEMOGRAM

HB - 4.4-6.7-6.1-5.9-6.0-6.3-8.5-8.9-7.6-7.6-7.8 MG/DL

TLC - 5500-3400-5960-6980-6190-8700-12200-11400-6500-7900- 8300 CELLS/MM3

PLT - 90K - 80K- 96K-1.40L-1.58L-1.1L-1.5L-1.82L-2.10L -2.4L

Treatment Given(Enter only Generic Name)

IV FLUIDS NS AT 100ML/HR

NEB WITH DUOLIN 6TH HRLY

INJ PAN 40MG IV/OD

INJ ZOFER 4MG IV/SOS

INJ LASIX 40MG IV/BD

INJ METROGYL 500MG IV /TID

INJ METHYLPREDNISOLONE 1GM IV/OD

INJ NTG 2CC IV GIVEN

TAB NICARDIA 10MG PO/SOS

TAB CLINIDIPINE 10MG PO/BD

TAB WYSOLONE 40MG PO/OD

TAB SPOROLAC DS PO/BD

TAB HCQ 200MG PO/OD

TAB AZATHIOPRINE 50MG PO/OD

SYP SUCRALFATE 10ML TID BEFORE FOOD

TAB MET XL 25MG PO/OD


Advice at Discharge

TAB NICARDIA 30MG AT 8AM , 20MG AT 2PM , 30MG AT 8PM

TAB HCQ 200MG PO/OD

TAB MET-XL 25MG PO/OD

TAB AZATHIPRINE 50MG PO/OD

TAB WYSOLONE 30MG/PO OD 20MG AT 8AM 10MG AT 6PM

TAB PAN 40MG PO/OD

TAB ZOFER 4MG PO/SOS

TAB LASIX 40MG PO/TID

SYP SUCRALFATE 10ML PO/TID BEFORE MEALS

Follow Up

REVIEW SOS OR AFTER 1 WEEK TO GENERAL ME







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