1801006026 -long case.
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A 29 year old female who is a resident of akkenepalli came to the medicine opd with the cheif complaints of Decreased urine output,pedal edema and facial puffiness since 5 days.
HISTORY OF PRESENT ILLNES
Patient was apparently asymptomatic 6 years back then she developed generalised body ache and joint pains in the knee and elbow and ulcers in the oral cavity and hair loss with out scarring for which she went to hospital and was diagnosed with an autoimmune condition SYSTEMIC LUPUS ERYTHEMATOSIS and initiated on hydroxychloroquine, azathioprine,wysolone.
She also reported that her joint pains and her hair loss was not improving with the above medications and visited many hospitals and had multiple admissions but not subsided.
But she is continuing her medication but in November 2022 she developed shortness of breath which was sudden in onset while she is getting ready to go to her office and brought to hospital and was diagnosed as kidney failure and she had dialysis for 4 times with 3 days gap and also diagnosed as hypertensive and given antihypertensives ( nicardia 30mg) and doctor also advised to stop the drugs(hydroxychloroquine , azathioprone,wysolone)for 2 months .
After 2 months that is in February 2023 she was admitted in hospital withthe history of vomitings , diarrhea since 10 days and was diagnosed as acute kidney injury on chronic kidney failure.
Since then she is coming to hospital for dialysis once in 3 to 4 days .
Yesterday that is on 15 March 2023 she came with the complaints of pedal edema which is of pitting type since 5 days which is insidious in onset gradually progressed form ankle to knee .patient also developed puffiness around the eyes which is prominent at morning after waking up.
PAST HISTORY:
A known case of hypertension since 5 months that is in November 2022 which is secondary to kidney failure and was on regular medications .
Not a known case of diabetes ,Tuberculosis,asthma ,Epilepsy.
FAMILY HISTORY :
No such similar complaints in the family .
Only her mother has diabetes and hypertension.
PERSONAL HISTORY :
Diet:mixed
Appetite :decreased
Bowel and bladder regular .
Sleep adequate
No addictions.
DAILY ROUTINE :
Patient is a customer service executive she wakes at 7 am daily and goes to bathroom and fresh up and does bath and her mother prepare her box she goes to office daily at 8 Am and and at 10 :30 am she eats her breakfast and drinks tea and agains continues her work till 1:30 and she will have her lunch at 1:30and continues her work till 6 pm and again reaches home at 7pm and she takes bath and help her daughter in studies till 9 :30 pm and then she watch TV till 11 pm or talks to neighbors or with her mother and she goes to at 11 pm .
But Since February 2023 she is not going to her work due to regular dialysis .
MENSTRUAL HISTROY:
Age of menarche:12 years.
Menstrual cycles :Her Menstrual cycles were irregular since 2 months.
Her last Menstrual period was Dec 25th 2022.
OBSTETRIC HISTORY
Para :2, live :1(full term normal vaginal delvery)
GENERAL EXAMINATION:
Patient is conscious coherent and cooperative. Thin built and Moderately nourished .
Vitals:Pulse rate :130 bpm
Respiratory rate :24 cycles per minute (regualr)
Blood pressure :160/100 mmhg
Temperature:Afebrile.
Patient has pallor and pedaledema which is of pitting type ,patient has flat nails,hyperpigmented discoid rashes on face,black discolouration of oral mucosa and palate.
No icterus,cyanosis ,clubbing ,lymphadenopathy.
CVS :
On palpation ‐
• Apex beat was felt in the left 5th intercostal space medial to the mid clavicular line.
• JVP was normal
• No precordial bulge
• No parasternal heave
On auscultation ‐ S1, S2 heard , no murmurs
RS :
On inspection ‐
• Chest is bilaterally symmetrical
• Expansion of chest: Equal on both sides
• Position of trachea: Central
• No visible scars, sinuses, pulsations
On palpation :
• Expansion of chest was equal on both sides.
• Position of trachea: Central
• Tactile Vocal Fremitus: resonant note was felt.
On percussion: all lung areas were resonant
On auscultation :
• Bilateral air entry was present, normal vesicular breath sounds were heard.
• Vocal resonance: resonant in all areas
P/A : soft, non tender, no organomegaly, no distension, bowel sounds heard.
CNS : The patient is well oriented to time, place, person.
Higher mental functions are intact.
Cranial nerve examination :‐
All cranial nerves are intact and functioning.
Motor System Examination :‐
• Normal bulk in upper and lower limbs
• Normal tone in upper and lower limbs
• Normal power in upper and lower limbs
• Gait is normal .
. Reflexes are normal .
Sensory System Examination :‐
Normal sensations are felt in all the dermatomes.
INVESTIGATIONS:
15.03.2023
Blood urea -79 mg/dl (N=12 to 42 mg/dl)
Serum creatinine-4mg/dl(N -0.6 to 1.1)
Serum electrolytes-
Na :141mEq/L(N-136 to 145)
K:3.5mEq/L(N:3.5 to 5.1)
Cl:102mEq/L(N=98 to 107)
Ionized ca+2:1.01mmol/L.
14.02.2023
HEMOGRAM:
Hb 8.5gm/dl.
Total count:12000 cell /cumm
Neutrophils:83 %
Lymphocytes:11%
Pcv:24.3 volume %
Platelets :l.lL / cumm.
Impression :Normocytic normochromic anemia with neutrophilic lymphocytes and thrombocytopenia.
Renal function test:
Urea:157mg/dl
Creatinine :6.9 mg/dl.
Uric acid :6.5 mg/dl.
ECG:
Chronic renal failure secondary to lupus nephritis.
Known case of sle
Treatment:
Tab Nicradia 30mgperoral thrice a day.
Tab lasix 40mg per oral two times a day .
Tab wysolone peroral twice a day .
Tab azathioprine 50 mg per oral once daily.
Tab hydroxychloroquine 200mg peroral once daily.
Tab Met xL 25 mg per oral once daily.
Tab nodosis 500mg per oral once daily.
Tablet shelcal 500mg po od
Tab orofer xt po od
Tab Pan 40mg po od.
Tab blod3 personal weekly twice .
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