22yr old diagnosed case of SLE with abdominal distension
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
22 year old female presented with
Complaints of abdominal distension , swelling lower limbs since 10 days
History of present illness:
She was apparently alright 3 years ago , which was 6 months after her first child birth, then she developed multiple joint pains, abdominal distension and shortness of breath . She visited
One year later (11/22) she also developed severe loose stools, cough , vomitings and admitted at an outside hospital.She also had complaints of excessive hair loss, loss of appetite , loss of weight, for further evaluation she was referred to higher center where she was thoroughly investigated
HEMOGRAM : Pancytopenia
LFT :Hypoalbuminemia
RFT : Creatinine 1.63
Urea 45
CUE: 2+ PROTEINURIA
Chest X Ray : Pleural effusion
ANTI NUCLEAR ANTIBODIES: 4+
Anti dsDna : +
C3, C4 : low
CECT ABDOMEN
And PROVISIONAL DIAGNOSIS of SLE with LUPUS NEPHRITIS, PANCYTOPENIA SECONDARY TO DISEASE ACTIVITY WITH AIHA WITH POLYARTHRITIS AND POLYSEROSISTIS ( Pleural effusion, ascites,mild pericardial effusion) was done
She was started on
Tab Prednisolone 60 mg for 1 week f/b 50mg for 1 week tapering doses
Tab HYDROXYCHLOROQUINE 200MG PO HS
She used the medication regularly and went for regular checkups
4 months later (3/23) she developed pedal edema and facial puffiness for which was admitted again at the same hospital ,was diagnosed as nephrotic syndrome and kidney biopsy was done
She was then started on INDUCTION THERAPY of MYCOPHENOLATE MOFETIL
TAB MYCOPHENOLATE MOFETIL 360 mg
Tab PREDNISOLONE 15 mg
Tab HYDROXYCHLOROQUINE 200 MG to be continued
She has been on regular follow up since then and using medication
3 months back due to financial reasons she couldn't afford MYCOPHENALATE MOFETIL tablets and hence stopped using them but is using HYDROXYCHLOROQUINE 200 mg
Now she presented with complaints of abdominal distension and lower limbs swelling since 10 days
Menstrual history
Irregular
LMP 30/7/23
Urine pregnancy test not done
On examination
Patient is conscious, coherent, co operative
Well oriented to place, person and time
Pallor present
Pedal Edema present
No icterus , cyanosis, clubbing, generalised lymphadenopathy.
VITALS at admission
Bp 180/100mmhg
Pulse 100 bpm
RR 17cpm
Temperature 98.7
SpO2 99
CVS
S1,S2 heard, no murmurs
RESPIRATORY EXAMINATION
BAE +
NORMAL VESICULAR BREATH SOUNDS
CNS
No focal neurological deficit
PER ABDOMEN:
SOFT , PALPABLE UTERUS CORRESPONDING TO 18 WEEKS OF GESTATION
immediately UPT was sent and found to be positive
OBGY REFFERAL WAS DONE
Investigations
DIAGNOSIS
22 year old G2P1L1 female with 14 weeks,3 days gestational age with one previous LSCS with SLE with AIHA with nephrotic syndrome , lupus nephritis class 3
Treatment
Tab NIFEDIPINE 10 mg PO TID
Tab FERROUS ASCORBATE 100mg PO OD
Tab Hydroxychloroquine 200 mg PO BD
Strict vitals monitoring
Strict input output monitoring
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