A 19 year old already diagnosed with SLE came with red scars on lower abdomen and mild facial swelling
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Presence of any four or more criteria of the 11( serially or simultaneously during any period of observation) is diagnosed as SLE.
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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.
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
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 7.3
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.
PAST HISTORY
Not a k/c/o diabetes mellitus, hypertension, asthma, T.B, epilepsy, CAD
No past Surgical history
No blood transfusions
PERSONAL HISTORY
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
GENERAL EXAMINATION
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
