A 19year old female k/c/o SLE came with complaints of red pigmentation on the abdomen

 This is an a online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

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.

CASE PRESENTATION 

A 19 year old female student  who is resident of narketpally came to general medicine OPD   who is a k/c/o SLE came with complaints of red scars on lower abdomen since 3 months and axilla since 1 week which are slowly progressive not associated with itching and bleeding., 

HISTORY OF PRESENTING ILLNESS 

Patient was apparently asymptomatic 1 year ago she then had low grade fever associated with chills, headache , vomiting then joint pains and alopecia in the month of November and December  2021. Then investigations were done and diagnosed with SLE. 

SLE CRITERIA 

CLINICAL FEATURES 

Presence of any four or more criteria of the 11( serially or simultaneously during any period of observation) is diagnosed as SLE.

1. Malar rash :+

2. Discord rash : +

3. Photo sensitivity : +

4.oral ulcers : +

5.Arthritis : +

6. Serositis : -

7. Renal disorder: - 

8.neurological disorder : - 

9. Hematological disorder: - +( hemolytic anema, leucopenia)

10. Immunological criteria

        Anti DNA - + 

        Anti sm - +

     Abnormal titre of ANA - +  

      Coombs test - +

She came with  similar complaints in the month of march- her Hb is 7.3mg/do

On examination diffuse thinning of hair 

Medication - WYSOLONE 40mg , AZATHIOPRINE 50 mg

Tab. OROFER -XT /OD 4 weeks

In the month of August she came with complaints of foul smelling white discharge since 2 months associated with pain.

Medication- CANDIDA v cream

Presently, 

She came for routine check up on examination there were deep pigmented red scars on the lateral side of abdomen since 3 months and light pigmented red scars near the axilla since 1 week and there is a mild facial swelling.

There was tapering of the drug dose

PAST HISTORY 

Not a k/c/o  diabetes mellitus, hypertension, asthma, T.B, epilepsy, CAD 

No past Surgical history 

No blood transfusions 

PERSONAL HISTORY 

Unmarried

Mixed diet

Loss of appetite 

Adequate sleep 

Bowel and bladder movements are normal 

No addiction 

FAMILY HISTORY 

Not relevant 

MENSTRUAL HISTORY 

Age of Menarche 12 years 

Menstrual cycle  4/30

LMP 15/12/2022

BIRTH HISTORY

Caeserean delivery

IMMUNISATION HISTORY

Upto mark

GENERAL EXAMINATION 

Gait: normal

Patient is conscious coherent and cooperative 

Moderately built 

Moderately nourished 

Pallor mild 

No icterus, cyanosis, clubbing of fingers, lymphadenopathy, pedal edema

VITAL SIGNS 

Temperature : 98.2F

Pulse Rate : 78 bpm

Blood pressure :  110/70 mm Hg 

Respiratory rate : 17

Spo2 : 98 percent 

GRBS : 107 mg/dl

SYSTEMIC EXAMINATION 

CVS 

S1 and S2 heard

No murmurs 

No thrills

RESPIRATORY SYSTEM:

No dyspnea

No wheeze

Central location of trachea

Normal Vesicular breath sounds heard

ABDOMEN-

Abdomen is scaphoid.

No tenderness

No palpable mass

Non palpable liver and spleen

Bowel sounds are not heard

CENTRAL NERVOUS SYSTEM 

Conscious 

Speech- normal

Signs of meningeal irritation - 

      no neck stiffness

Cranial system - intact 

Motor system - intact 

Sensory system - intact 

 Cerebeilar signs

  Finger nose- in coordination

  Knee heel - in coordination

PROVISIONAL DIAGNOSIS 

SLE associated with iatrogenc cushings

INVESTIGATIONS 

TREATMENT 

1.Vital monitoring 4 hrly 

2.with hold prednisolone and azathioprine 50 mg