Medicine prefinal practical


 This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box.

  M.sri sai pavan. Roll no : 79 

 
30 year old female patient came to OPD with chief complaints of fever, rashes , joint paints.

History of present illness
Patient apparently asymptomatic 2 years ago then she developed  fever, rashes , joint pains 
 Then she went to local hospital where they had given  some antibiotics and pain killers
   
Symptoms  subsided and recurred after some time
She continued  to take this medication but symptoms started  to reccur
 Lastly she went to private hospital  where she was  diagnosed as systemic lupus erythamatosis

 It was diagnosed by renal biopsy and ANA profile 
 Which was 
  • Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN
  • Biposy showed focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS, a
  • Proteinuria  and increased creatinine.                She has history of  hair loss

    Initially 3 days of her treatment after diagnoses she developed facial puffiness blurring of vision the 
    She had on treatment
     
     She was put on Tab. OMNOCORTIL 50 mg for 3 days and steroid injections and was tapered over 6 months to 2.5mg. and she is taking hydroxy chloroquine along with this 


    After 6 months, steroids were stopped and was started on

    •  Tab. MFM (2 tab at 8 AM and 1 tab at 8 PM), after that she had symptoms for which they added methotrexate to  it  after few weeks.
    • IN FEBRUARY 2021, She was started on METHOTREXATE  after which she noticed increase in number of oral ulcers , so she went to a private hospital 15 days later, and was started again  on OMNOCORTIL 5mg
    • She later developed blurring of vision more in day light, for which she was diagnosed with cataract in her left eye.
    After that she stopped steroid usage but she is on MFM and HCQS till this  day

     After that she lost vision on both eyes and under went cataract surgery on Feb 12 
     From last 6 months she is having mouth ulcers on and off 
     But from last 7 days she is having increased symptoms of ulcers, joint pains ,fever such that
    She is not able swallow foods  with this history she came to this hospital .

    Past history : 

    Patient is a known case of HYPOTHYROIDISM since 4 years  and is on Thyronorm 50mcg .
    Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA

    PERSONAL HISTORY:

    DIET- mixed
    Appetite: Normal
    Bowel and bladder movements are normal
    Sleep: Adequate
    No known addictions and allergies.

    Menstrual History:
    She bleeds for 3 days in a 30 day cycle 
    She uses 3 pads per day.
    Recently, she complains of spotting 5 days before her first day of menses ( oligomenorrhea)

    Marital history:

    In 2014 Dec, when she was 24 years When she got  married. 

    Antenatal history:
    P3 L2 A1
    In 2015, her first pregnancy reached full term and NVD was done. 
    She developed high grade fever in her 6th month, and was diagnosed with malaria.
    She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

    In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication. 

    In 2019, her third pregnancy, reached full term and NVD was done. 

    Family History:
    Insignificant

    General examination: 

    Patient is conscious, coherent and cooperative. 

    Vitals on admission:                                                Temp: 102°F

BP: 120/80

PR: 110 bpm



CVS: S1 S2 present N

o murmurs or thrills heard 



RS: BAE present, NVBS heard 



CNS: E4V5M6



P/A: soft, non tender 

Investigations.    

Hemogram: 

Hb: 9.3

TLC: 3500

N/L/E/M: 78/15/2/5

Plt: 2.3



CUE: 

Albumin: trace 

Sugars: nil

Pus cells: 2-3 

Epithelial cells: 2-3 



APTT: 32s

PT: 16s

INR: 1.11
TIME LINE OF EVENTS 
X ray :
ECG:
FEVER CHART:
CLINICAL IMAGES:





Provisional diagnosis: SYSTEMIC LUPUS ERYTHEMATOSUS - CLASS III LUPUS  NEPHRITIS
 With hypothyroidism 

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