fever projr sle 25/F

 sle 

date of admission 9/10/2023 

date of discharge 20/10/2023




Diagnosis

SYSTEMIC LUPUS ERYTHEMATOSIS

PYODERMA GANGRENOSUM

ANEMIA SECONDARY TO CHRONIC INFLAMMATION

?SLE PSYCHOSIS

HYPOTONIC HYPONATREMIA

ANTERIOR WALL HYPOKINESIA

Case History and Clinical Findings

PATIENT WITH C/O FEVER SINCE 3 MONTHS , PAIN ABDOMEN SINCE 1 MONTH

HOPI:

PATIENT WAS APPARENTLY ASYMPTOMATIC 3 MONTHS AGO THEN SHE HAD FEVER WHICH IS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , HIGH GRADE , INTERMITTENT IN NATURE , ASSOCIATED WITH CHILLS , TEMPORARILY RELIEVED ON MEDICATION , NOT ASSOCIATED WITH COUGH , COLD , BURNING MICTURITION

H/O PAIN IN ABDOMEN , DIFFUSE IN NATURE, DRAGGING TYPE , NON RADIATING , ASSOCIATED WITH BLOATING AND TIGHTNESS

NO C/O VOMITINGS , LOOSE STOOLS

H/O SOB SINCE 1 MONTH WHICH IS INSIDIOUS IN ONSET , GRADUALLY PROGRESSIVE , AGGREVATED ON EXERTION AND RELIEVED BY TAKING REST , NOT ASSOCIATED WITH ORTHOPNEA , PND , PALPITATIONS

NOT ASSOCIATED WITH PEDAL EDEMA , DECREASED URINE OUTPUT

WEIGHT LOSS SINCE 3 MONTHS

JOINT PAINS SINCE 3 MONTHS

H/O HAIR FALL SINCE 3 MONTHS

HYPERPIGMENTED PATCHES OVER CHEST SINCE 1 MONTH

H/O 2 EPISODES OF GENERALISED TONIC SEIZURES 5 DAYS BACK FOR ABOUT 2 MINUTES WITH UPROLLING OF EYE BALLS , LIP BITE AND NO INVOLUNTARY MICTURITION , DEFECATION , FROTHING FROM MOUTH

H/O AMENORRHEA SINCE 4 MONTHS

PAST HISTORY:

PATIENT HAD A H/O BUTTERFLY SHAPED HYPERPIGMENTED PATCH OVER CHEEKS 3 YEARS BACK DURING HER PREGNANCY

PERSONAL HISTORY:

MIXED DIET

APPETITE DECREASED

BOWEL AND BLADDER - REGULAR

NO ADDICTIONS

MENSTRUAL HISTORY:

LMP IN JUNE

AOM: 14 YEARS 5/30 PREVIOUSLY REGULAR CYCLES i.e, 4 MONTHS AGO

GENERAL EXAMINATION:

PATIENT IS CONSCIOUS,COHERENT,COOPERATIVE

PATIENT IS THIN BUILT AND POORLY NOURISHED

ALOPECIA PRESENT

HYPERPIGMENTATION OVER CHEST PRESENT

MULTIPLE ULCERS OVER ELBOWS AND LEGS

PALLOR PRESENT

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

VITALS-

TEMP- 101` F

PR-140 BPM

RR-20 CPM

BP-120/80MMHG

SPO2- 98% AT RA

GRBS- 80 MG/DL

CVS- S1,S2 HEARD , NO MURMERS

RS- BLAE PRESENT , NO ADDED SOUNDS

P/A- SOFT, NON TENDER

NO ORGANOMEGALY

CNS- NO FND PRESENT

OBG REFERRAL WAS DONE ON 11/10/23 I/V/O AMENORRHEA SINCE 3 MONTHS

ADV -

HVS

UPT WHICH CAME NEGATIVE

DERMATOLOGY REFERRAL WAS DONE ON 11/10/23

ADV-

FUDIC CREAM L/A BDX 1 WEEK

UROLOGY REFERRAL WAS DONE

ADV-

LIMIT WATER INTAKE

SYP CREMAFFIN 15ML H/S X 2 WEEKS

T.TAMSULOSIN 0.4MG PO /HS X 2WEEKS

SYP.ALKASTONE B6 15ML 1/2 GLASS OF WATER PO/SOS

PSYCHIATRY REFERRAL WAS DONE I/V/O PSYCHOSIS

ADV-

T.CLONAZEPAM 0.25 MG MD STAT

T.OLANZAPINE 2.5MG

T.CLONAZEPAM 0.25 MG MD PO/SOS

INJ.LORAZEPAM 1/2 AMP 2MG IM/SOS (IF PATIENT IS IRRITABLE)

COURSE IN THE HOSPITAL:

PATIENT CAME WITH ABOVE MENTIONED COMPLAINTS AND TREATED CONSERVATIVELY , SHE HAD ACUTE RETENTION OF URINE FOR WHICH UROLOGY WAS TAKEN AND FOLEYS WAS PLACED AND SUSPECTED AS SLE , AND DERMA REFERRAL WAS TAKEN AND SKIN BIOPSY WAS TAKEN AND SENT FROM THE SKIN ULCER . GYNAEC REFERRAL WAS TAKEN AND HIGH VAGINAL SWAB WAS SENT WHICH SHOWED ECOLI . ANA PROFILE WAS SENT WHICH SHOWED ANTI DS DNA , ANTI SS A , ANTI SS B POSITIVE SO DIAGNOSED AS SLE AND THEN STARTED ORAL STEROIDS i.e, T.PREDNISOLONE 30 MG . HER FEVER SPIKES DECREASED . NCCT KUB WAS DONE I/V/O RIGHT MILD HYDROURETERONEPHROSIS . PSYCHIATRY REFERRAL WAS TAKEN I/V/O PSYCHOSIS

Investigation

NameValue

Range

NameValueRangeHBsAg-RAPID09-10-2023 05:24:PMNegative

Anti HCV Antibodies - RAPID09-10-2023 05:24:PMNon Reactive

COMPLETE URINE EXAMINATION (CUE) 09-10-2023 05:24:PM

COLOUR

Pale yellow

APPEARANCE

Clear

REACTION

Acidic

SP.GRAVITY1.010

ALBUMIN+

SUGARNil

BILE SALTSNil

BILE PIGMENTSNil

PUS CELLS3-4

EPITHELIAL CELLS2-3

RED BLOOD CELLSNil

CRYSTALSNil

CASTSNil

AMORPHOUS DEPOSITSAbsent


OTHERSNil

BLOOD UREA09-10-2023 05:24:PM20 mg/dl42-12 mg/dlSERUM CREATININE09-10-2023 05:24:PM0.7 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 09-10-2023 05:24:PM SODIUM125 mEq/L

145-136 mEq/L

POTASSIUM3.9 mEq/L

5.1-3.5 mEq/L

CHLORIDE96 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.00 mmol/Lmmol/LLIVER FUNCTION TEST (LFT) 09-10-2023 05:24:PM Total Bilurubin1.30 mg/dl

1-0 mg/dl

Direct Bilurubin0.40 mg/dl

0.2-0.0 mg/dl

SGOT(AST)80 IU/L

31-0 IU/L

SGPT(ALT)20 IU/L

34-0 IU/L

ALKALINE PHOSPHATE667 IU/L

98-42 IU/L

TOTAL PROTEINS5.8 gm/dl

8.3-6.4 gm/dl

ALBUMIN1.83 gm/dl

5.2-3.5 gm/dl

A/G RATIO0.46

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 10-10-2023 07:41:AM SODIUM122 mEq/L

145-136 mEq/L

POTASSIUM4.0 mEq/L

5.1-3.5 mEq/L

CHLORIDE98 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.06 mmol/Lmmol/LSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 10-10-2023 10:44:PM SODIUM124 mEq/L

145-136 mEq/L

POTASSIUM3.3 mEq/L

5.1-3.5 mEq/L

CHLORIDE98 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.10 mmol/L

mmol/L

PERIPHERAL SMEAR11-10-2023 09:14:AMRBC : Normocytic normochromic WBC : counts increased on smear with neutrophils predominant PLATELET : Adequate SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 11-10-2023 11:19:PM SODIUM125 mEq/L

145-136 mEq/L

POTASSIUM3.5 mEq/L

5.1-3.5 mEq/L

CHLORIDE98 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.00 mmol/L

mmol/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 12-10-2023 10:25:PM SODIUM129 mEq/L

145-136 mEq/L

POTASSIUM4.0 mEq/L

5.1-3.5 mEq/L

CHLORIDE97 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.07 mmol/L

mmol/L

SERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 15-10-2023 11:17:PM SODIUM124 mEq/L

145-136 mEq/L

POTASSIUM3.4 mEq/L

5.1-3.5 mEq/L

CHLORIDE95 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.05 mmol/L

mmol/L

BLOOD UREA17-10-2023 10:50:PM10 mg/dl42-12 mg/dlSERUM CREATININE17-10-2023 10:50:PM0.6 mg/dl1.1-0.6 mg/dlSERUM ELECTROLYTES (Na, K, C l) AND SERUM IONIZED CALCIUM 17-10-2023 10:50:PM SODIUM130 mEq/L

145-136 mEq/L

POTASSIUM3.3 mEq/L

5.1-3.5 mEq/L

CHLORIDE99 mEq/L

98-107 mEq/L

CALCIUM IONIZED1.08 mmol/Lmmol/LLIVER FUNCTION TEST (LFT) 17-10-2023 10:50:PM Total Bilurubin0.50 mg/dl

1-0 mg/dl

Direct Bilurubin0.15 mg/dl

0.2-0.0 mg/dl

SGOT(AST)96 IU/L

31-0 IU/L

SGPT(ALT)21 IU/L

34-0 IU/L

ALKALINE PHOSPHATE717 IU/L

98-42 IU/L

TOTAL PROTEINS6.3 gm/dl

8.3-6.4 gm/dl

ALBUMIN2.08 gm/dl

5.2-3.5 gm/dl

A/G RATIO0.49

SWAPNA HPE REPORT :

IMPRESSION - FEATURES SUGGESTIVE OF PYODERMA GANGRENOSUM

NCCT KUB PLAIN -

IMPRESSION - NO ABNORMALITY IN CT KUB

DIFFUSE FATTY INFILTRATION OF LIVER

BLOOD FOR C/S- ON 15/10/23

NO GROWTH AFTER 1 WEEK OF AEROBIC INCUBATION

SWAB FROM ULCER- ON 16/10/23

PEUDOMONAS AERUGINOSA ISOLATED

SWAB FOR C/S - ON 14/10/23

ESCHERECHIA COLI ISOLATED

URINE C/S ON 11/10/23-

POLYMICROBIAL FLORA GROWN

BLOOD C/S ON 11/10/23 -

NO GROWTH AFTER 24 HOURS OF AEROBIC INCUBATION

ANA PROFILE-

SHOWED ANTI DS DNA , ANTI SS A , ANTI SS B POSITIVE

DIRECT COOMBS TEST ON 12/10/23 - POSITIVE

2D ECHO - ON 10/10/23

TRIVIAL TR PRESENT / MR PRESENT , NO AR

RWMA PRESENT, ANTERIOR WALL HYPOKINESIA , NO AS/MS

FAIR LV FUNCTION

NO DIASTOLIC DYSFUNCTION . NO PAH/PE

USG -

IMPRESSION -

GRADE I FATTY LIVER

MILD ASCITES

INTERNAL ECHOES NOTED IN THE BLADDER ?CYSTITIS CORRELATE WITH

RIGHT MILD HYDROURETERONEPHROSIS

HEMOGRAM ON 18/10/23

HB- 5GM/DL

TLC- 5000 CELLS/CUMM

PLT- 4.2 LAKHS/CUMM

UPT 0N 12/10/23 - NEGATIVE

Treatment Given(Enter only Generic Name)

IN.NEOMOL 1GM IV/SOS

INJ.MONOCEF 1GM IV/BD X 6 DAYS

TAB.PREDNISOLONE 30MG PO/OD X 6 DAYS

TAB.PREDNISOLONE TAPERED TO 20MG

TAB.HCQ 200MG PO/O

TAB.OLANZAPINE 2.5MG PO/HS

SYP.ALKASTONE B6 15ML IN 1/2 GLASS OF WATER H/S

Advice at Discharge

TAB.PREDNISOLONE 20MG PO/OD X 2 WEEKS --> PREDNISOLONE 10MG PO/OD X 1 MONTH

TAB.HCQ 200MG PO/OD X 1 MONTH

TAB.AUGMENTIN 625MG PO/BD X 5 DAYS

SYP.ALKASTONE B6 15ML IN 1/2 GLASS OF WATER H/S X 1 WEEK


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