general medicine finals
29 YEARS OLD FEMALE WITH COMPLIANTS AND DURATION:
PIGMENTATION OVER FACE-6 MONTHS
HAIR FALL FROM SCALP- 6MONTHS
HISTORY OF LOSS OF APPETITE
HISTORY OF FEVER-6 MONTHS
HISTORY OF JOINT PAIN:6MONTHS
HISTORY OF MORNING STIFFNESS
HISTORY OF PEDAL EDEMA
HISTORY OF ULCERS IN ORAL CAVITY:5MONTHS
HOPI :
PATIENT WAS APPARENTLY ASYMPTOMATIC BEFORE 15 NOVEMBER 2021.
ON 15 NOVEMBER 2021 PATIENT STARTED DEVELOPING FEVER , SWELLING AT SYNOVIUM OF ANKLE JOINT WHICH LATER LEAD TO PEDAL EDEMA AND ASSOCIATED WITH REDUCED PLATELET COUNT FOR WHICH SHE WAS TAKEN TO A NEARBY HOSPITAL WHERE SHE RECEIVED THE TREATMENT AND LATER DURING THE HOSPITAL STAY SHE DEVELOPED PAIN IN ALL JOINTS ASSOCIATED WITH SWELLING AND EARLY MORNING STIFFNESS SINCE THEN. ALSO DEVELOPED PIGMENTATION OVER FACE , SCALP, BOTH EARS , NECK, BOTH HANDS AND LEGS, ARMS AND FOREARMS FOLLOWING WHICH SHE DEVELOPED ORAL ULCERS, THROAT PAIN WHICH IS ON AND OFF , THINNING OF HAIR AND HAIRFALL
PAST HISTORY :
HISTORY OF ABORTION
HISTORY OF SEZIURES
NO HISTORY OF DIABETES MELLITUS
NO HISTORY OF HTN
PREVIOUS SURGERIES : HYSTERECTOMY
PERSONAL HISTORY :
DIET : MIXED
APPETITE : REDUCED
SLEEP : INADEQUATE
BOWEL AND BLADDER : REGULAR
GENERAL EXAMINATION:
PATIENT IS C/C/C
NO PALLOR, ICTERUS , CYANOSIS
BILATERAL PEDAL EDEMA +
VITALS :
BP - 110 / 70 mmhg
PR - 98 bpm
SPO2 - 99% @RA
TEMP - FEVER SPIKES
SYSTEMIC EXAMINATION :
CVS - S1 S2 +
RS - BAE +
CNS : NAD
INVESTIGATIONS
ECG:
PROVISIONAL DIAGNOSIS : SYSTEMIC LUPUS ERYTHEMATOSUS .
TREATMENT :
31/5/2022
PHOTO BAN CREAM (TID)
TAB CLONAZEPAM 0.5MG
2/6/2022:
TAB ULTRACET1/2 TAB OID
WYSOLONE 20MG OD
TAB HCQ 10MGBD
6/6/2022:
TAB ULTRACET 1/2 TAB OD
TAB HCQ 10MG BD
ING NEOMAL 1G I. V
TAB WYSOLONE:20 MG OD
