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’ŠΉοΈŽοΈŽοΈŽ H/o itching present over plaques 
π’ŠΉοΈŽοΈŽοΈŽ H/o photosensitivity 
π’ŠΉοΈŽοΈŽοΈŽ Swelling restrictions of movements persistent 
π’ŠΉοΈŽοΈŽοΈŽ C/o Wrist joint pain (+)
π’ŠΉοΈŽοΈŽοΈŽ C/o Metacarpo phalanges pain (+)
π’ŠΉοΈŽοΈŽοΈŽ C/o Interphalanges pain (+)
π’ŠΉοΈŽοΈŽοΈŽ C/o Tenderness present over wrist,mcp, Ip
π’ŠΉοΈŽοΈŽοΈŽ H/o fever & episode in last 8months
π’ŠΉοΈŽοΈŽοΈŽ Last episode 20days back
π’ŠΉοΈŽοΈŽοΈŽ Fever last for 1day relieved after taking medication
π’ŠΉοΈŽοΈŽοΈŽ 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’ŠΉοΈŽοΈŽοΈŽ H/o CVA  left Up & Ll weakness &slured speech  10 years back
π’ŠΉοΈŽοΈŽοΈŽ H/o Appendectomy 8year back 
π’ŠΉοΈŽοΈŽοΈŽ N/k/c/o DM, HTN,TB,Epilepsy,CAD, 
π’ŠΉοΈŽοΈŽοΈŽ Used Ayurvedic medication 2 months back for 15days

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

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

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

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

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

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

π’ŠΉοΈŽοΈŽοΈŽ 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’ŠΉοΈŽοΈŽοΈŽ USG :-
-small shrunken Right kidney with grade-3     RPD changes 
 - Grade-2 fatty liver with mild hepatomegaly
 - Right renal cortical cyst 

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

 π’ŠΉοΈŽοΈŽοΈŽ 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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