19 year old girl with history of fever, joint pains and vomitings
19 YEAR OLD GIRL WITH HISTORY OF FEVER, JOINT PAINS AND VOMITINGS
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Systemic examination :
Treatment :
A 19 year old girl, hailing from Narketpally, came to the OPD with chief complaints of vomitings since 4days.
History of present illness : The patient was apparently asymptomatic 3 months back, then she developed intermittent low grade fever that releived on taking dolo. As the fever subsided, the patient started experiencing multiple joint pains ( IP, MCP, WRIST, ELBOW, SHOULDER, KNEE, ANKLE joints ). The patient described the pain as a needle-like pain especially in the morning and night. She also had swelling of her left elbow and wrist joint. When she took medications (hydroxychloroquine, aceclofenac) , her pain was releived but as she stopped her medications, she was again experiencing pain. The patient also complaints of repeated oral ulcers since she had fever. She also complaints of excessive hair loss (alopecia) since 3 months. The patient also had vomitings which was non bilious, projectile with food as contents.
Past history : has no history of allergies , asthma, epilepsy, TB, any thyroid disorders
Personal history : She completed her intermediate and is staying at home now.
Diet ‐ mixed
Appetite ‐ decreased since 3 months
Sleep ‐ adequate
Bowel and Bladder movements ‐ regular
General Examination: the patient is conscious, coherent, cooperative, moderately built and nourished.
Mild pallor is present.
Icterus, cyanosis, clubbing, generalised lymphadenopathy, pedal edema are absent.
Erythematous rash is seen on the nasal bridge and cheeks.
VITALS :
16‐02‐2022
Temperature ‐ 97.3F
Pulse rate ‐ 68 bpm
BP ‐ 110/60 mmHg
17‐02‐2022
Temperature ‐ afebrile
BP ‐ 110/80 mmHg
PR ‐ 74bpm
Systemic examination :
CVS : S1 , S2 heard, no murmurs
RS :BAE + ,NVBS heard
P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard
CNS: no focal neurological deficits
Investigations :
17-02-2022 : Hb ‐ 7.3, TLC ‐ 16,600, Platelets ‐ 48,000
ANA test : Positiveds DNA test : Positive
Provisional diagnosis : SLE with anemia and thrombocytopenia
1) Injection methylprednisolone 1gm IV Stat
2) Tablet paracetamol 650mg QID
3) Tablet pantop 40mg OD
4) Tablet zofer 4mg BD
5) IV fluids ‐ NS, RL, DNS ‐ 75ml/hr
DISCUSSION:
Systemic lupus erythematosus (SLE) is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels. There is no cure for lupus, but medical interventions and lifestyle changes can help control it.
The SLEDAI is a global index that measures disease activity within the last 10 days. It includes 24 clinical and laboratory variables that are weighted by the type of manifestation, but not by severity.
SLEDAI ‐ 2K CLINICAL CRITERIA FOR THE DIAGNOSIS OF SLE :
Activity categories have been defined on the basis of SLEDAI scores: no activity (SLEDAI=0), mild activity (SLEDAI=1 to 5), moderate activity (SLEDAI=6 to 10), high activity (SLEDAI=11 to 19), and very high activity (SLEDAI≥20).
CLINICAL TRIAL :
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