45F SYSTEMIC LUPUS ERYTHEMATOSIS

This is 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 patients 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 comment box is welcome .



Chief complaints: 
Patient c/o itchy skin lesions over back, hands, neck, face since 3 months. 
C/o fever since 2 months (1episode every day) 
C/o oral ulcers since 1 month 
C/o joint pain since 15 days 

HOPI: 
Patient was apparently normal 3 months back, when her complaints started as itchy skin lesions over back which progressed to hands. 
C/O high grade, continuous fever, 1 episode per day, relieved on taking medication. 
H/o painful oral ulcers since 1 month, associated with difficulty in swallowing and burning sensation. 
C/o joint pains since 15 days associated with swelling 
No h/o morning stiffness.
H/o photosensitivity present.

H/o usage of
- TAB. OMNACORTIL 30MG
- TAB AUGMENTIN 625MG
- BETAMETHASONE LOTION
- CANDID MOUTH PAINT


No occult blood present in stools. 
No h/o new drug intake prior to symptoms 
No h/o dry eyes, mouth, raynauds phenomenon
No h/o chest pain, dysnea, palpitations

Past history:
K/c/o elephatiasis of right leg since 30 years 
N/K/C/O DM2, HTN, CAD, ASTHMA, TB, EPILEPSY, CVD, CAD, THYROID DISORDER 

GENERAL EXAM: 

Patient is examined in a well lit room after taking informed consent. 
Patient is conscious, coherent and cooperative. 
She is moderately built and moderately nourished. 

Pallor: Present 
Icterus: absent
Cyanosis: absent
Clubbing: absent 
Generalized Lymphadenopathy: Absent
Edema: Absent

Vitals: 
Temp: 97F 
BP: 120/80mmhg 
PR: 84 bpm 
RR: 16 cpm 
GRBS: 98

SYSTEMIC EXAMINATION : 

Cardiovascular System:

INSPECTION: 
-Chest wall: bilaterally symmetrical
-Apical impulse and pulsations cannot be seen.
-No dilated veins, scars, sinuses. 

PALPATION:
-Apical impulse is felt on the left 5th intercoastal space, 2cm lateral from the midline.
-No parasternal heave and thrills were felt.

PERCUSSION:
-Right and left heart borders percussed.

AUSCULTATION:
- S1 and S2 heard, no added thrills and murmurs heard
    
Central Nervous System:

No neurological deficit, patient's higher mental functions are intact. 

Abdominal Examination:

INSPECTION: 
• Abdomen is scaphoid 
• Flanks are free
• Umbilicus is normal in shape and position
• No visible scars or sinuses
• No visible gastric peristalsis
• No distended veins

PALPATION: 
• No local rise of temperature
• No tenderness
• No organomegaly 

PERCUSSION 
• Fluid thrill absent 

AUSCULTATION
• Bowel sounds normal


Respiratory Examination:

Examination done in sitting position. 

INSPECTION: 
     - Normal

Inspection of Lower Respiratory Tract:  
     - Trachea is central in position
     - Chest is symmetrical in shape
     - Movement of the chest is equal
     - Abdomino-thoracic type of breathing


PALPATION:
     - Trachea is central in position. 
     -  Chest is expanding symmetrically. 

PERCUSSION: 
     - All areas were resonant. 


AUSCULTATION: 
     - Bilateral air entry present. 
     - Normal vesicular breath sounds. 
     

Skin: 
O/E: 
Multiple oral ulcers noted over bilateral buccal mucosa, hard palate
Multiple polysized hyperpigmentated plaques with crusting noted over face, neck, hands, back, abdomen. 
Diffuse loss of hair over scalp
Non pitting edema of right lower limb 
Multiple polysized hyperpigmentated macules noted over bilateral cheeks, forehead.


ECG: 

29/05/23 

30/05/23: 
31/05/23
01/06/23

02/06/23
Treatment: 
1. TESS PASTE L/A TID (20MIN BEFORE FOOD) 
2. TAB. TECZINE 10MG OD 
3. SUNCROS AQUAGEL L/A SPF 50 TID 
4. TAB. ZINCOVIT OD 
5. FUDIC CREAM L/A BD 
6. TAB. PREDNISOLONE 20MG OD 
7. TAB. PAN 40MG OD (BBF) 
8. TAB. TELMA 40MG PO/OD AT 8AM 


X-ray spine:
Impression: 
Mild degenerative changes notes in the cervical spine. 


Ophthal referral: 
On fundus examination, no changes of hypertensive retinopathy, noted in both eyes. .

Gastroenterology Referral: 
Esophageal candidiasis

2D echo: 

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