CHIEF COMPLAINTS
- Itchy skin lesions over the body since 8 months
- joint pains ( wrists, knuckles, IPJ, ankle) since 5 months
- burning sensation of palate since 2 months
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 8 months ago, then he developed small papules over the cheek which was initially white in color and then turned erythematous, then involved are the nose, cheek, entire face, neck, back, hands and legs.
H/O itching over the plaques which was more on exposure to sunlight, hot water and extreme cold water. After itching the skin would become scaly and pale pink in color.
H/O photosensitivity
He then developed pain in the joints which was more on movement and after heavy work and relieved by rest. There was also stiffness, swelling of the joints. He then also developed cyclic fevers, 4 episodes in the last 5 months, more during the nighttime. Last episode 20 days ago.
He then developed burning sensation over the palate 2 months ago which was more for spicy food.
No H/O chest pain, sob, palpitations
No H/O CVA
PAST HISTORY
Not a known case of Hypertension. Diabetes, tuberculosis, CVD, thyroid disorders, epilepsy
H/O appendectomy 8 years ago
H/O left UL, LL weakness and slurred speech 10 years ago.
Used ayurvedic medicine 1 month ago for 15 days
FAMILY HISTORY
No relavent family history
PERSONAL HISTORY
Diet: mixed
Appetite: decreased since 3 days
Bowel and bladder: Normal
Sleep: Adequate
Addictions: alcohol consumption since 20 years ( 125 ml daily)
Smoking since 25 years (beedi 1 pack per day)
GENERAL EXAMINATION
Patient is consious, coherent and cooperative.
Well oriented to time place and person
Moderately built and moderately nourished.
No Pallor, Icterus, Cyanosis, Clubbing, lymphadenopathy, Edema
On Examination:
Temp: afebrile
PR- 80 bpm
BP: 100/70 mmHg
RR: 18 cpm
Sp02: 95% at room air
SYSTEMIC EXAMINATION
RESPIRATORY SYSTEM:
UPPER RESPIRATORY TRACT:
No halitosis, post nasal drip, tonsils, dental caries, dns, polyps, sinus tenderness
Oral hygiene present
LOWER RESPIRATORY TRACT:
INSPECTION:
Chest is symmetrical in shape
Trachea is in the midline (trails sign)
Apical impulse not visualised
No drooping of shoulder, supraclavicular and infraclavicular hollowing, indrawings, retractions, crowding of ribs
No pectus carinatum, pectus excavatum, kyphoscoliosis, winging of scapula
No sinuses, scars, dilated veins, nodules
Normal movements with respiration
PALPATION:
No local rise of temperature
All inspectory findings confirmed
Expansion of the chest is symmetrical
Tactile vocal fremitus: normal
PERCUSSION:
Resonant note
AUSCULTATION:
Normal
CVS:
S1, S2 heard
PER ABDOMEN:
Soft non tender
CNS:
No focal neurological deficits
PROVISIONAL DIAGNOSIS:
Systemic lupus erythematous? Lupus nephritis (grade 3 rpd changes)? With CKD stage 2, viral pyrexia with bicytopenia( thrombocytopenia and leukopenia)
CLINICAL FINDINGS:
INVESTIGATIONS:
SERUM CREATININE: 1.2 mg/dl
BLOOD UREA: 12 mg/dl
SERUM ELECTROLYTES:
- Sodium: 139 mEq/L
- Potassium: 3.7 mEq/L
- Chloride: 106 mEq/L
- Calcium ionized: 1.08 mmol/L
RBS: 85 mg/dl
TREATMENT:
1. SUNCROS AQUAGEL SPF 50 L/A
2. MUCOPAIN GEL L/A TID
3. T.PCM 650 MG PO TID
4. T.BENFOMET PLUS PO OD
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