35 yrs old male with? SLE

 This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.  

Chief complaints:-

Itchy skin lesions all over the body since 8 months 

History of present illness:-

Patient was apparently alright 8 months back then he developed small papules over the cheek after which it transformed into erythematous scaly plaques first on the nose and cheek then over the entire face,neck,back,hands and legs.

H/o itching over the plaques

H/o photosensitivity 

C/o Tenderness in wrist joint, metacarpophalangeal joint,interphalangeal joint 

H/o fever 4 episodes in last 8 months,last episode 20 days back.fever lasts for one day releived after taking medication.

H/o oral ulcers on hard palate since 10days

No chest pain,sob, palpitations

No abdominal pain,nausea vomiting 

No increased or decreased output 

H/o cva, left UL ,LL weakness and slurred speech 10 years back 

H/o apendectomy 8 years back 

Used ayurvedic medicine  1 month back for 15 days.

Past history:- not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy

Family history:- not significant

Personal history:- 

Appetite:- decreased since 3 days

Diet:- mixed

Sleep :- adequate

B& B :- regular 

Addictions :- toddy drinker since 20 years 

Bedi smoker since 25 years(15 per day)

General examination:- 

Patient is conscious, coherent, cooperative well oriented to time place and person .

Moderately built, moderately nourished

Pallor:- absent 

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent 

                  

     

Vitals:- 

Bp:100/70 mmhg 

Pulse rate:-80 bpm 

RR:- 18 cycles per min

Temp :- afebrile

Systemic examination:-

Cvs :- s1,s2 heard no murmurs

Cns :- no focal neurological deficits 

Abdomen :- soft ,non tender 

Rs:- BAE present 

Investigations:- 

 x - ray :-

Ecg:-

USG report:-

2decho report:-

                     On 5/4/23

7/4/23

8/4/23

Provisional diagnosis:-

Systemic lupus erythematous?lupus nephritis( grade lll rpd changes)?with CKD stage ll, viral pyrexia with bicytopenia(thrombocytopenia,leukopenia)

k/c/o CVA 10 years back

Treatment:- 

SUNCROS AUQAGEL SPF 50 L/A

MUCOPAIN GEL L/A TID

T.PCM 650 MG PO TID

T.BENFOMET PLUS PO OD