SLE

20 year old female with b/ l pedal edema


This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

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


Durga sri

131

Presentation 

https://youtu.be/GFASTNR78Ng


20 year female came to casualty with chief complaints of 

-Hyperpigmented macules since 15 days

-b/l pedal edema since 15 days 

Fever 15 days back

-abdominal distension since 8 days 

-cough(dry) since 7 days 

-Sore throat since 7 days 

-decreased appetite since 7 days 

-decreased urine output since 3 days 

-constipation since 3 days 

-SOB since 5 days

HOPI 

20 year old female came with c/o of b/l pitting type pedal edema extending till knees since 15 days to which she got medical health checkup and prescribed some medication (unknown) then her pedal edema got resolved along with fever she developed Hyperpigmented macules on face later they stopped medications after 2 days she again had a complaints of b/l pedal edema  and fever abdominal distension associated with dry cough and decreased appetite she also has a complaints of DECREASED urine output and constipation since 3 days passing stools once in 3 to 4 days  

History of pastillness

N/k/c/o HTN DM THYROID DISORDER CAD EPILEPSY TB










Personal history: 

Mixed diet 

Appetite lost 

Non veg diet 

Bowel and bladder movements are decreased 

Family history :

No significant family history 

O/E :

Pt was c/c/c 

On admission vitals are 

Bp 110/70 

PR 79 

RR 19 

Temp 98.8 


CVS- apex beat replaced laterally palpable thrills and s1 s2 heard mild s3

RS - BAE decreased rt infra scapular crepts present

P/a umblicus is everted

CNS   pt was conscious coherent cooperative

MMSE 








         https://youtu.be/XUOFp5odTnw



https://youtube.com/shorts/9YYfuCgbNl8?feature=share






https://youtube.com/shorts/ZN8AZcvPjYs?feature=share






https://youtu.be/8-tpKi6TZ_A


Investigations:

X ray



30/9/22 

USG




EcG
28/09/22


Pleural tap






RFT

LFT













ANA PROFILE


Provisional diagnosis

FLARE UP SLE WITH 

LUPUS NEPHRITIS 

CNS LUPUS VASCULITIS


https://08arshewarpavankumar.blogspot.com/2022/09/20-yr-female-with-bl-pedal-edema.html?m=1


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