29 YEAR OLD FEMALE WITH SLE

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CASE DETAILS :
29 YEAR OLD FEMALE CAME TO OPD WITH COMPLAINTS OF POLYARTHRITIS , SWELLING WITH EARLY MORNING STIFFNESS IN JOINTS,  HAIR FALL, ORAL ULCERS SINCE 3 MONTHS

HOPI :
PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 15 NOVEMBER 2021.
ON 15 NOVEMBER 2021 PATIENT STARTED DEVELOPING FEVER , SWELLING AT SYNOVIUM OF ANKLE JOINT WHICH LATER LEAD TO  PEDAL EDEMA AND  ASSOCIATED WITH REDUCED PLATELET COUNT FOR WHICH SHE WAS TAKEN TO A NEARBY HOSPITAL WHERE  SHE RECEIVED THE TREATMENT AND LATER DURING THE HOSPITAL STAY SHE DEVELOPED PAIN IN ALL JOINTS ASSOCIATED WITH SWELLING AND EARLY MORNING STIFFNESS SINCE THEN. ALSO DEVELOPED PIGMENTATION OVER FACE , SCALP, BOTH EARS , NECK, BOTH HANDS AND LEGS, ARMS AND FOREARMS FOLLOWING WHICH SHE DEVELOPED ORAL ULCERS, THROAT PAIN WHICH IS ON AND OFF , THINNING OF HAIR AND HAIRFALL SINCE 1 MONTH 
NO HISTORY OF PHOTOSENSITIVITY,  RAYNAUDS PHENOMENON 

PAST HISTORY :
H/O 1 EPISODE OF SEIZURES  3 YEARS BACK AFTER SUDDEN DEMISE OF PATIENT'S SISTER.
1 YEAR LATER SHE HAD PARALYSED LEFT UL AND LL,  FOR WHICH SHE WAS TAKEN TO A HOSPITAL AND WAS PUT ON TAB. EPITOIN 100 mg / TID. PATIENT STOPPED MEDICATION 1 MONTH BACK
H/O ASTHMA DURING ( 2006 TO 2010) AND NOW SUBSIDED
NOT A K/C/O HTN , DM 
SURGICAL HISTORY: C SECTION  , HYSTERECTOMY 

PERSONAL HISTORY :
DIET : MIXED
APPETITE : REDUCED
SLEEP : INADEQUATE 
BOWEL AND BLADDER : REGULAR

GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +



VITALS :
BP - 110 / 70 mmhg
PR - 98 bpm
SPO2 - 99% @RA
TEMP - AFEBRILE 

SYSTEMIC EXAMINATION :
CVS - S1 S2 +
RS - BAE +
CNS : NAD


INVESTIGATIONS :

22/04/2022



27/04/2022


ECG:
2D ECHO :

USG :
CHEST X RAY - PA VIEW :

22/04/2022
27/04/2022


FEVER CHART


PROVISIONAL DIAGNOSIS : SYSTEMIC LUPUS ERYTHEMATOSUS .

TREATMENT :
1. TAB. ULTRACET 1/2 tab /Qid
2. BETADINE ORAL MOUTH WASH 3 TIMES A DAY
3. TAB. DOLO 650 MG / (SOS)
4. TAB. ZINCOVIT /OD
5. IVF - DNS @50 ML/HR
6. TAB. PAN D 40 MG PO /OD
7. SYP. ARISTOZYME 10 ML / TID

SOAP NOTES DAY 2
 23/04/2022

AMC ADMISSION :

S:
NO FRESH COMPLAINTS 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +

VITALS :
BP - 110/70 MMHG
PR- 90 BPM
SPO2 - 98%
TEMP - 98.2° F
GRBS - 101 MG/DL
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , NON TENDER
CNS - NAD


SYSTEMIC LUPUS ERYTHEMATOSUS 


P:
1. TAB. WYSOLONE 20 MG / PO/ OD
2. TAB. ULTRACET PO/ 1/2 tab /Qid
3. BETADINE ORAL MOUTH WASH 3 TIMES A DAY
4. TAB. DOLO 650 MG / (SOS)
5. OINT. THROMBOPHOBE ( L/A )
6. IVF - DNS @50 ML/HR
7. TAB. RABICER D  PO /BD
8. SYP. ARISTOZYME PO 10 ML / TID
9. TAB. NAPROXEN 250 MG PO/ TID

SOAP NOTES - DAY 3
 24/04/2022

AMC ADMISSION :

S:
PATIENT COMPLAINTS OF COUGH WITH SPUTUM SINCE LAST NIGHT 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +

VITALS :
BP - 110/80 MMHG
PR- 90 BPM
SPO2 - 98%
TEMP - 98.2° F
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , TENDERNESS PRESENT IN RT & LT HYPOCHONDRIUM
CNS - NAD

A:
SYSTEMIC LUPUS ERYTHEMATOSUS 


P:
1. TAB. WYSOLONE 20 MG / PO/ OD
2. TAB. ULTRACET 1/2 tab /Qid
3. BETADINE ORAL MOUTH WASH 3 TIMES A DAY
4. TAB. DOLO 650 MG / (SOS)
5. OINT. THROMBOPHOBE ( L/A )
6. IVF - DNS @50 ML/HR
7. TAB. PAN D 40 MG PO /OD
8. SYP. ARISTOZYME 10 ML / TID
9. TAB. RABICER D PO/BD


SOAP NOTES - DAY 4
25/04/2022

AMC ADMISSION :

S:
COUGH REDUCED ON MEDICATION 
JOINT PAINS ARE SLIGHTLY REDUCED BUT AGGRAVATE DURING EARLY MORNING 
PATIENT UNABLE TO EAT DUE TO INCREASED NAUSEA 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +

VITALS :
BP - 110/80 MMHG
PR- 92 BPM
SPO2 - 98%
TEMP - 98.2° F
GRBS - 97 MG/DL
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , NON TENDER
CNS - NAD


SYSTEMIC LUPUS ERYTHEMATOSUS 


P:
1. TAB. WYSOLONE 20 MG / PO/ OD
2. TAB. ULTRACET PO/ 1/2 tab /Qid
3. BETADINE ORAL MOUTH WASH 3 TIMES A DAY
4. TAB. DOLO 650 MG / (SOS)
5. OINT. THROMBOPHOBE ( L/A )
6. IVF - DNS @50 ML/HR
7. TAB. RABICER D  PO /BD
8. SYP. ARISTOZYME PO 10 ML / TID
9. SYP. ASCORYL 10 ML / TID
10. INJ. ZOFER 4MG IV /SOS


SOAP NOTES DAY 5
 26/04/2022

AMC ADMISSION :

S:
NO FRESH COMPLAINTS 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +

VITALS :
BP - 110/70 MMHG
PR- 90 BPM
SPO2 - 98%
TEMP - 98.2° F
GRBS - 101 MG/DL
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , NON TENDER
CNS - NAD

A:
SYSTEMIC LUPUS ERYTHEMATOSUS 


P:
1. TAB. WYSOLONE 20 MG / PO/ OD
2. TAB. ULTRACET PO/ 1/2 tab /Qid
3. BETADINE ORAL MOUTH WASH 3 TIMES A DAY
4. TAB. DOLO 650 MG / (SOS)
5. OINT. THROMBOPHOBE ( L/A )
6. IVF - DNS @50 ML/HR
7. TAB. RABICER D  PO /BD
8. SYP. ARISTOZYME PO 10 ML / TID
9. SYP. ASCORYL 10 ML / TID
10. INJ. ZOFER 4MG IV /SOS


SOAP NOTES DAY 6
 27/04/2022

AMC ADMISSION :

S:
INCREASED JOINT PAINS 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA  +

VITALS :
BP - 120/80 MMHG
PR- 82 BPM
SPO2 - 98%
TEMP - AFEBRILE 
GRBS - 101 MG/DL
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , NON TENDER
CNS - NAD

A:
SYSTEMIC LUPUS ERYTHEMATOSUS 


P:

1. TAB CEFIXIME 200 MG PO/ BD
2. TAB. WYSOLONE 20 MG / PO/ BD
3. TAB . NAPROXEN 250 MG PO/TID
4. TAB. DOLO 650 MG / TID
5. TAB. RABICER D  PO /OD
6. SYP. ARISTOZYME PO 10 ML / TID
7. OINT. THROMBOPHOBE FOR ( L/A )
8. SYP. ASCORYL 10 ML / TID
9. TAB. HCQ 100 MG /BD

SOAP NOTES DAY 7
 28/04/2022

AMC ADMISSION :

S:
REDUCED JOINT PAINS 
NO FRESH COMPLAINTS 

O: 
PATIENT IS C/C/C
NO PALLOR,  ICTERUS , CYANOSIS
REDUCED PEDAL EDEMA 

VITALS :
BP - 110/90 MMHG
PR- 90 BPM
SPO2 - 98%
TEMP - AFEBRILE 
CVS - S1 S2 +
RS - BAE +
P/A - SOFT , NON TENDER
CNS - NAD

A:
SYSTEMIC LUPUS ERYTHEMATOSUS 


P:

1. TAB CEFIXIME 200 MG PO/ BD
2. TAB. WYSOLONE 20 MG / PO/ BD
3. TAB . NAPROXEN 250 MG PO/TID
4. TAB. RABICER D  PO /OD
5. SYP. ARISTOZYME PO 10 ML / TID
6. SYP. ASCORYL 10 ML / TID
7. TAB. HCQ 100 MG /BD

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