19 year old girl with history of fever, joint pains and vomitings

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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.

A 19 year old girl, hailing from Narketpally,  came to the OPD with chief complaints of vomitings since 4days.

History of present illness : The patient was apparently asymptomatic 3 months back, then she developed intermittent low grade fever that releived on taking dolo. As the fever subsided, the patient started experiencing multiple joint pains ( IP, MCP, WRIST, ELBOW, SHOULDER, KNEE, ANKLE joints ). The patient described the pain as a needle-like pain especially in the morning and night. She also had swelling of her left elbow and wrist joint. When she took medications  (hydroxychloroquine, aceclofenac) , her pain was releived but as she stopped her medications,  she was again experiencing pain. The patient also complaints of repeated oral ulcers since she had fever. She also complaints of excessive hair loss  (alopecia) since 3 months. The patient also had vomitings which was non bilious, projectile with food as contents.

Past history : has no history of allergies , asthma, epilepsy,  TB, any thyroid disorders 

Personal history : She completed her intermediate and is staying at home now.

Diet ‐ mixed

Appetite ‐ decreased since 3 months

Sleep ‐ adequate

Bowel and Bladder movements ‐ regular 

General Examination: the patient is conscious,  coherent,  cooperative,  moderately built and nourished.

Mild pallor is present.

Icterus, cyanosis, clubbing,  generalised lymphadenopathy,  pedal edema are absent. 

Erythematous rash is seen on the nasal bridge and cheeks.

VITALS : 

Temperature ‐ 97.3F

Pulse rate ‐ 68 bpm

BP ‐ 110/60 mmHg

Systemic examination : 

CVS : S1 , S2 heard, no murmurs 

RS :BAE + ,NVBS heard 

P/A :soft , non tender ,no organomegaly ,no distension ,bowel sounds heard

CNS: no focal neurological deficits

Investigation

ANA test : Positive

ds DNA test : Positive

Provisional diagnosis : SLE with Anaemia and Thrombocytopenia

Treatment :

1) Injection methylprednisolone 1gm IV Stat

2) Tablet paracetamol 650mg QID

3) Tablet pantop 40mg OD

4) Tablet zofer 4mg BD

5) IV fluids ‐ NS, RL, DNS ‐ 75ml/hr

DISCUSSION:

Systemic lupus erythematosus (SLE) is an autoimmune disease in which the immune system attacks its own tissues, causing widespread inflammation and tissue damage in the affected organs. It can affect the joints, skin, brain, lungs, kidneys, and blood vessels. There is no cure for lupus, but medical interventions and lifestyle changes can help control it.