SLE - LAXMI NARYANA

A  35yr old male came to causality with chief complaints of itching skin lesions all over body since 8months 

π‡πˆπ’π“πŽπ‘π˜ πŽπ… ππ‘π„π’π„ππ“πˆππ† πˆπ‹π‹ππ„π’π’ :-

Patient was apparently asymptomatic 8months ago the he developed small papulesbover cheek after which it transformed into erythematous scaly plaque first on nose cheek then over entire face, neck ,back ,hand and to  legs 
π’ŠΉ︎︎︎ H/o itching present over plaques 
π’ŠΉ︎︎︎ H/o photosensitivity 
π’ŠΉ︎︎︎ Swelling restrictions of movements persistent 
π’ŠΉ︎︎︎ C/o Wrist joint pain (+)
π’ŠΉ︎︎︎ C/o Metacarpo phalanges pain (+)
π’ŠΉ︎︎︎ C/o Interphalanges pain (+)
π’ŠΉ︎︎︎ C/o Tenderness present over wrist,mcp, Ip
π’ŠΉ︎︎︎ H/o fever & episode in last 8months
π’ŠΉ︎︎︎ Last episode 20days back
π’ŠΉ︎︎︎ Fever last for 1day relieved after taking medication
π’ŠΉ︎︎︎ H/o oral ulcer on hard palate since 10days 

π‡πˆπ’π“πŽπ‘π˜ πŽπ… 𝐏𝐀𝐒𝐓 πˆπ‹π‹ππ„π’π’ :-

π’ŠΉ︎︎︎ H/o CVA  left Up & Ll weakness &slured speech  10 years back
π’ŠΉ︎︎︎ H/o Appendectomy 8year back 
π’ŠΉ︎︎︎ N/k/c/o DM, HTN,TB,Epilepsy,CAD, 
π’ŠΉ︎︎︎ Used Ayurvedic medication 2 months back for 15days

ππ„π‘π’πŽππ€π‹ π‡πˆπ’π“πŽπ‘π˜  :-

π’ŠΉ︎︎︎ Married
π’ŠΉ︎︎︎ Occupation -driver
π’ŠΉ︎︎︎ Appetite-decrease 
π’ŠΉ︎︎︎ Mixed diet 
π’ŠΉ︎︎︎ Bowel- Regular 
π’ŠΉ︎︎︎ Micturition-normal
π’ŠΉ︎︎︎ Habit/addiction 
π’ŠΉ︎︎︎ Alcohol-toddy dinner since 20yr 
π’ŠΉ︎︎︎ Occasionall alcoholic
π’ŠΉ︎︎︎ BD since 25year (15 per day)

π…π€πŒπˆπ‹π˜ π‡πˆπ’π“πŽπ‘π˜ :-

π’ŠΉ︎︎︎ No similar complaints in the family. 

ππ‡π˜π’πˆπ‚π€π‹ π‡πˆπ’π“πŽπ‘π˜ :-

(1) GENERAL HISTORY :-

Height-                                   Weight-

Pallor-absent 
Icterus- absent                             Clubbing-absent
Cynosis- absent                            Oedema -absent 
Lymphadenopathy-absent           
 No Malnutrition 
No Dehydration 

π’ŠΉ︎︎︎ Vitals:-        Temp-Afebrile
                     Pulse rate -82/min
                     Respiratory rate-20/min
                     BP -100/70mmHg

π’π˜π’π“π„πŒπˆπ‚ π„π—π€πŒπˆππ€π“πˆπŽπ :-

π’ŠΉ︎︎︎ CVS -   Cardic sound S1&S2 heard
            Cardic mummers- No

π’ŠΉ︎︎︎ Respiratory system :-No Dyspnoea
                                      No Wheeze
                          Position of trachea -central
                         Breath sounds -vesicular(normal)
                          B/L air entry -Normal 

π’ŠΉ︎︎︎ Abdomen :-  Shape of abdomen - scaphoid 
                       Tenderness-No
                   Palpable masses- No organomegaly 
                        Liver- Not palpable 
                        Spleen- not palpable 
                        Bowel sounds - yes 
                        Hernial orifices- Normal

π’ŠΉ︎︎︎ CNS - level of consciousness -conscious 
              Speech- Normal
              No Signs of meningical irritation ( neck stiffness, kernigs signs)
                Cranial  nerves-normal
                 Motor system- normal
                  Sensory system-normal 
                  Glasgrow scale
πˆππ•π„π’π“πˆπ†π€π“πˆπŽππ’ :-
π’ŠΉ︎︎︎ USG :-
-small shrunken Right kidney with grade-3     RPD changes 
 - Grade-2 fatty liver with mild hepatomegaly
 - Right renal cortical cyst 

π’ŠΉ︎︎︎ 2D ECHO :-
 - Good LV systolic function 

 π’ŠΉ︎︎︎ HAEMOGRAM -

ππ‘πŽπ•πˆπ’πˆπŽππ€π‹ πƒπˆπ€π†ππŽπ’πˆπ’ :-

 π™Žπ™”π™Žπ™π™€π™ˆπ™„π˜Ύ π™‡π™π™‹π™π™Ž π™€π™π™”π™π™ƒπ™€π™ˆπ˜Όπ™π™Šπ™π™Ž 

π“π‘π„π€π“π„πŒπ„ππ“ :- 

- MUCOPAIN GEL-  thrice daily
- T. PCM-650 - thrice daily
- T.BENFOMET PLUS- once daily
- T.PREGABALIN- once daily
- T.BACLOFENX-L- once daily
- T.LORAZEPAM - once daily
- T.NICOTINE GUMS- twice daily
- T. HCQ-200mg/BD

 π€πƒπ•πˆπ‚𝐄 :- 
No active intervention Needed from nephrology

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