General medicine: March 2022

K.sannith reddy

Roll no:55

30 year old female patient came to OPD with chief complaints of fever, rashes , joint paints.

History of present illness

Patient apparently asymptomatic 2 years ago then she developed fever, rashes , joint pains

Then she went to local hospital where they had given some antibiotics and pain killers

Symptoms subsided and recurred after some time

She continued to take this medication but symptoms were going to reccur

Lastly she went to private hospital there she diagnosed her as systemic lupus erythamatosis

It was diagnosed by renal biopsy and ANA profile

Which was

Anti -RNP/ Sm and Anti- Sm, Anti-Jo 1, Anti - ds DNA, nucleosomes and RIBOSOMAL P- PROTEIN
Biposy showed focal mild increased endocapillary cellularity pointing towards FOCAL GLOMERULONEPHRITIS
Proteinuria and increased creatinine.

She has history of hair loss

Initially 3 days of her treatment after diagnoses she developed facial puffiness blurring of vision the

She had on treatment

She was put on Tab. OMNOCORTIL 50 mg for 3 days and steroid injections and was tapered over 6 months to 2.5mg. and she is taking hydroxy chloroquine along with this

After 6 months, steroids were stopped and was started on

Tab. MFM (2 tab at 8 AM and 1 tab at 8 PM), after that she had symptoms for which they added methotrexate to it after few weeks.
IN FEBRUARY 2021, She was started on METHOTREXATE after which she noticed increase in number of oral ulcers , so she went to a private hospital 15 days later, and was started again on OMNOCORTIL 5mg
She later developed blurring of vision more in day light, for which she was diagnosed with cataract in her left eye.

After that she stopped steroid usage but she is on MFM and HCQS till this day

After that she lost vision on both eyes and under went cataract surgery on Feb 12

From last 6 months she is having mouth ulcers on and off

But from last 7 days she is having increased symptoms of ulcers joint pains fever such that

She is not able swallow foods with this history she came to this hospital .

Past history :

Patient is a known case of HYPOTHYROIDISM since and is on Thyronorm 50mcg .

Not a known case of DM, HTN, EPILEPSY, TB, BRONCHIAL ASTHMA

PERSONAL HISTORY:

DIET- mixed

Appetite: Normal

Bowel and bladder movements are normal

Sleep: Adequate

No known addictions and allergies.

Menstrual History:

She bleeds for 3 days in a 30 day cycle

She uses 3 pads per day.

Recently, she complains of spotting 5 days before her first day of menses ( oligomenorrhea)

Marital history:

In 2014 Dec, when she was 24 years she was a married.

Antenatal history:

P3 L2 A1

In 2015, her first pregnancy reached full term and NVD was done.

She developed high grade fever in her 6th month, and was diagnosed with malaria.

She developed severe back and loin pain in her 8th month, and USG was done which showed swollen kidneys for which she was prescribed antibiotics and sent home.

In 2018, her second pregnancy, she suffered an abortion in the 4th month. On investigation, she was found to be suffering from Hypothyroidism and was started on medication.

In 2019, her third pregnancy, reached full term and NVD was done.

Family History:

Insignificant

General examination:

Patient is conscious, coherent and cooperative.

Vitals on admission:

Temp: 102°F

BP: 120/80

PR: 110 bpm

CVS:

On palpation,

-Apex beat felt at 5th intercostal space along midclavicular line