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CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
DR. SIRAJ AHMED SARKI
FCPS-II TRAINEE
@ PAEDS UNIT III
CHILDREN HOSPITAL LRK
 A 12 ½ year old female
child named IQRA D/O
AMANULLAH , resident of
JACOBABAD admitted via
ER in pediatrics unit iii
children hospital larkana
on 18/03/2023 with
complaints of…
 Fever for 7 days
 Abdominal distension
for 6 days
 My historian was patient herself According to her
She was relatively better 7 days back then she
developed Fever that was subjectively low grade,
intermittent in pattern and relieved by taking
antipyratics with No special time of occurrence.
Associated with headache (generalized mild in
intensity) However, fever was Not associated with
shivering, cough, rashes, ear pain, ear discharge,
sore throat, joint pain, Burning micturation,
diarrhea, night sweats, and bleeding from any site.
 ABDOMINAL DISTENSION
on 2nd day of fever she noticed abdominal
distension that was gradual in onset started at
left upper abdomen than progress to involve
whole abdomen, associated with abdominal pain
(that was generalized, gradual in onset, aching in
nature, mild in intensity, no radiation, referral or
shift, no aggravating or relieving factors) not
associated with vomiting, constipation, diarrhea,
bleeding per rectum and SOB
 GENERAL : decreased appetite but no h/o weight loss no
sleep disturbance
 CNS: No convulsion, ALOC, blurred vision or weakness of any
part of body.
 CVS: no palpitation, no chest pain No cyanosis and edema of
feet
 Res: No respiratory distress, no hemoptysis
 GI : Jaundice is present in eyes for 7-8 months
 GUS: No dysuria, oligouria and Hematuria, color was yellow
 ENDO: no neck swelling, cold or heat intolerance, polydipsia
or polyuria
 MSK: No muscle/bone/joint pain,swelling, stiffness,
skeletal deformity, or restriction of movement
SKIN: no rashes, itching or colored spot, hair loss
 There has been only ONE Hospital admission for 1 day in july
2022 with complaints of FEVER, YELLOWISH DISCOLORATION ,
AND PALLOR some investigations (CBC, LFTs, MP, HBsAg and
U/S ABDOMEN) done and PCV was transfused at that time,
after that she has hx of multiple OPD VISITS from July to
December 2022 with persistent complaint of fever, yellowish
discoloration, abdominal pain and she was treated as case of
ACUTE HEPATITS, after that she remains relatively alright then
she develops presenting complaints and went to GP, and he
counseled the attendants for tertiary care hospital
 SURGICAL Hx was not significant except ears
piercing by her aunty (new needle)
 Birth hx unremarkable .
 She is vaccinated according to National
EPI schedule.
 Acheived normal developmental
milestones.
 Total amount of calories required according to
weight at the 12 ½ years of age 1780
k.calories/day.
 Current intake about 1350 k.calories/last 24 hours.
 2 cup tea 60k.cal
 biscuit 8, 280k.cal
 1 of chapatti two time/day 200k/cal
 sabzi two times 300k/cal
 1 glass milk given/day (120 k.calories)
 boiled egg 80k.cal
 boiled rice1 200k.cal
 1 banana 110 k.cal Def:
430kcal/Day
 Not started yet
 1 time PCV transfusion
 Hb 5.2 g/dl.
 blood group O+ve.
 blood was arranged from private laboratory.
 Donor was cousin
 blood transfused after proper blood grouping
screening and cross match
 No reaction was noted.
 Hx was not Significant
 ANTIMALARIAL
 MULTIVITAMINS
 SYP: BRUFEN
 FOLIC ACID
 ORAL ANTIBIOTICS
 SYP: SILVER
 SYP: OSNATE-D
 SYP: DUPHALEC
 SYP: MUCAINE
 SYP: HIMALAYA
50yr
Healthy
22y
45yr
Healthy
25y
married
5th
DOL
due
to fits
6th
DOL
due
to
fits
17y 14y
Pt; 9y
NO Hx of chronic illness in family
NO Hx of JAUNDICE in FAMILY
 No any addiction or habit
 Normal bowel habits
 No any psychosocial problem
 Student of class five
 Home and school surroundings are
satisfactory
7 family members
Living in well built house
Father is uneducated laborer by
occupation earn 25-30k/month
Source of water from hand pump
water
 NO Domestic animal at home.
 patient daily activities have disturbed
she is not able to continue his education,
previously she has good education record
 parents are disturbed financially and
psychologically and worried about disease of
his child because of repetitive opd visits.
Parents have poor knowledge about disease
they only know she has liver problem
 A 12 ½ year old female child 5th issue of
consanguineous marriage birth hx is unremarkable
vaccinated developmentally normal admitted with c/o
fever for 7days and abdominal distension for 6days
associated with headache & fatigue and jaundice since
july 2022. she has hx of hospital admission in July 2022
for 1 day with complaints of fever jaundice and pallor,
transfused with PCV once at that time, and having
multiple OPD visits b/c of fever jaundice and abd pain.
 Death of two siblings in family in neonatal age with FITS
 No h/o cough, glandular swelling, night sweats,rash,
ear discharge, sore throat, joint pain, Burning
micturation, diarrhea constipation, and bleeding from
any site.
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
 My patient is well looking, conscious and
cooperative sitting on bed having obvious
pallor with no obvious signs of respiratory
distress and dysmorphic features having…
 height 143 cm (at 75th percentile)
and
 weight 34kg (above 25th percentile)
VITALS:
R/R: 20 Br/Min
H/R 104 Bt/Min
TEMP 98.8f
BP: 110/70 mmHg (systolic at 50th and diastolic below 50th
percentile)
 SEVERE ANEEMIA and JAUNDICE are present
 NO koilonychia, Cyanosis, Clubbing, palmar
erythema, nodes, Dehydration, bruises,
petechie, discoloration, Pedal edema and
Lymphadenopathy
 Oral hygiene is satisfactory, ears, nose and
eyes are normal there is no neck swelling,
 BCG SCAR was PRESENT
SYSTEMIC EXAMINATION
 Inspection
Slightly Distended, moves with respiration, umbilicus is
centrally placed with inverted margins, no visible
marks/scars/pulsation/veins
 Palpation
 There was no tenderness
Spleen = palpable 6cm below left costal margin with regular
margins, smooth surfaces firm in consistency directed to RIF.
LIVER, KIDNEYS, BLADDER OR ANY MASS WAS NOT PALPABLE
Abdominal Girth: 60cm
 Percussion
Percussion note was dull on LUQ and in flanks regions,
NO Fluid thrill but Shifting dullness was positive
TOTAL LIVER SPAN WAS 8cm (upper border in 5th ICS)
 Auscultation
Bowel sounds audible
 CNS is grossly intact,Hearing and vision
intact,spine is normal.
 Lung= Are clear Bilaterally
 CVS: Apex beat is in 4th ICS, and JVP is not
raised, S1 and S2 audible no added sound
 MSK: no tenderness, swelling, discoloration,
stiffness, or joint pain on passive movements
 SMR: stage II
A 12 ½ year old female child 5th issue of
consanguineous marriage birth hx is unremarkable
vaccinated developmentally normal admitted with c/o
fever for 7days and abdominal distension for 6days
associated with headache, fatigue and jaundice. she has
hx of hospital admission in july 2022 for 1 day with
complaints of fever jaundice and pallor, transfused
with PCV once at that time, and having multiple opd
visits b/c of fever jaundice and abd pain.
Death of two siblings in family in neonatal age with FITS
 O/E
 well looking female child with average built and height,
conscious and cooperative sitting on bed comfortably, vitally
stable she looks pale and jaundiced NO koilonychia Cyanosis,
Clubbing, palmar erythema, nodes, Dehydration, bruises,
petechie, and Pedal edema and Lymphadenopathy.
BCG SCAR WAS PRESENT
Abdominal ex: slightly distended, non tender Spleen is palpable
6cm below left costal margin with regular margins, smooth
surfaces firm in consistency directed towards RIF.
LIVER, KIDNEYS, BLADDER OR ANY MASS WAS NOT PALPABLE
Percussion note was dull on LUQ and in flanks regions, Shifting
dullness is positive TLS is 8cm. bowels sounds audible
Rest of systemic Ex: including CVS, CNS, CHEST AND MSK was
UNREMARKABLE
 SMR: stage-II
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
 CHRONIC LIVER DISEASE 2NDRY T0…
1) Viral hepatitis?
2) Wilson disease?
3) Autoimmune hepatitis?
 ABDOMINAL T.B?
 MALIGNANCY?
 HIV?
 SLE?
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
 HB 5.2g/dl
 HCT 19.7%
 MCV 53.3fl
 WBC 4100/cmm
 PLT 203000/cmm
 MP-ICT… NEGATIVE
 SMEAR…
Microcytic
hypochromic
anisocytosis
poikilocytosis
 T. BILLI 15.7mg/dl
 D. Billi 10.5mg/dl
 SGPT 390 U/L
 ALK PHO 479 U/L
 Hepatosplenomegally
 PV diameter 5mm
 No free fluid seen
 HB 6.2g/dl
 HCT 22.4%
 MCV 51.4fl
 WBC 3000/cmm
 PLT 91000/cmm
 S. BILLI : 2.8mg/dl
 DIRECT: 1.5mg/dl
 SGPT : 159 U/L
 ALK PHO: 604 U/L
 MP-ICT P. VIVAX
SEEN
 HB 6.3g/dl
 HCT 20.8%
 RBC 3.78 millions/cmm
 MCV 55.1fl
 WBC 3700/cmm
 PLT 70000/cmm
 MP-ICT… NEGATIVE
 Anti-HIV N/R
 T.Billi 2.0mg/dl
 D.Billi 1.0mg/dl
 SGPT 50U/L
 ALK PHO 218U/L
 PT 15sec
 INR 1.07
 APTT 36sec
 RBS 106mg/dl
 Urea 26mg/dl
 Cre 0.7mg/dl
 V/M NEGATIVE
 Color.. Yellow
 Appearance.. clear
 pH.. 5.0
 S gravity.. 1.015
 Albumin.. nil
 Sugar.. nil
 Rbc.. Nil
 Puss cells.. Nil
 Epi cells 2-3/hpf
 Coarse texture of
liver
 Suggestive of CLD
 Mild Spleenomegally
 Moderate ascites
 PV diameter 10mm
 Interpretation:
WBC = 4700
HB = 7.2 g/dl
HCT= 24.0 %
RBC = 4.5 millions/dl
MCV= 53.3 fl
RDW= 32.1%
MCHC= 30g/dl
Plt=86000
SMEAR
microcytic, hypochromic,
anisocytosis and target
cells
RETICULOCYTES 1.0%
NO blast
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx
 0.19 g/l
 SLIGHTLY Below the
reference range for
age
 ANA … POSITIVE
 PATTEREN…
COARSE SPECKLED
 ASMA… NEGATIVE
 AMA… NEGATIVE
 25.7IU/ml
 positive
SYSTEMIC LUPUS ERYTHEMATOSIS
 INJ: CEFOTAXIME 1g i/v x 8 hourly
 INJ: VIT:K 2mg diluted in 5cc i/v stat
 Syp: Ibuprofen 200mg 2tsp x TDS
 Syp: duphalec 30ml x HS
 Syp: vidalyn 1tsp x OD
 Syp: silver 1tsp x BD
 Tab: aldacton 50mg ¾ x OD
 Tab: inderal 10mg 1x OD
 Tab: Deltacortil 5mg 4+0+3
 Tab: HCQ 200mg 1xOD
 Tab: Folic acid 1xOD
 Tab: Aldacton 100mg ¾ x OD
 Tab: Inderal 10mg 1xOD
 Syp: Osnate-D 1+1
 Syp: Mucaine 1xOD
 natural history of disease
 Complications of disease
 Complications of drugs
 Prognosis of disease with and without
treatment
 Avoid sun exposure
 Regular follow up
CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx

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CASE PRESENTATION BY DR SIRAJ AHMED CMC on SLE 2023pptx

  • 2. DR. SIRAJ AHMED SARKI FCPS-II TRAINEE @ PAEDS UNIT III CHILDREN HOSPITAL LRK
  • 3.  A 12 ½ year old female child named IQRA D/O AMANULLAH , resident of JACOBABAD admitted via ER in pediatrics unit iii children hospital larkana on 18/03/2023 with complaints of…  Fever for 7 days  Abdominal distension for 6 days
  • 4.  My historian was patient herself According to her She was relatively better 7 days back then she developed Fever that was subjectively low grade, intermittent in pattern and relieved by taking antipyratics with No special time of occurrence. Associated with headache (generalized mild in intensity) However, fever was Not associated with shivering, cough, rashes, ear pain, ear discharge, sore throat, joint pain, Burning micturation, diarrhea, night sweats, and bleeding from any site.
  • 5.  ABDOMINAL DISTENSION on 2nd day of fever she noticed abdominal distension that was gradual in onset started at left upper abdomen than progress to involve whole abdomen, associated with abdominal pain (that was generalized, gradual in onset, aching in nature, mild in intensity, no radiation, referral or shift, no aggravating or relieving factors) not associated with vomiting, constipation, diarrhea, bleeding per rectum and SOB
  • 6.  GENERAL : decreased appetite but no h/o weight loss no sleep disturbance  CNS: No convulsion, ALOC, blurred vision or weakness of any part of body.  CVS: no palpitation, no chest pain No cyanosis and edema of feet  Res: No respiratory distress, no hemoptysis  GI : Jaundice is present in eyes for 7-8 months  GUS: No dysuria, oligouria and Hematuria, color was yellow  ENDO: no neck swelling, cold or heat intolerance, polydipsia or polyuria  MSK: No muscle/bone/joint pain,swelling, stiffness, skeletal deformity, or restriction of movement SKIN: no rashes, itching or colored spot, hair loss
  • 7.  There has been only ONE Hospital admission for 1 day in july 2022 with complaints of FEVER, YELLOWISH DISCOLORATION , AND PALLOR some investigations (CBC, LFTs, MP, HBsAg and U/S ABDOMEN) done and PCV was transfused at that time, after that she has hx of multiple OPD VISITS from July to December 2022 with persistent complaint of fever, yellowish discoloration, abdominal pain and she was treated as case of ACUTE HEPATITS, after that she remains relatively alright then she develops presenting complaints and went to GP, and he counseled the attendants for tertiary care hospital  SURGICAL Hx was not significant except ears piercing by her aunty (new needle)
  • 8.  Birth hx unremarkable .  She is vaccinated according to National EPI schedule.  Acheived normal developmental milestones.
  • 9.  Total amount of calories required according to weight at the 12 ½ years of age 1780 k.calories/day.  Current intake about 1350 k.calories/last 24 hours.  2 cup tea 60k.cal  biscuit 8, 280k.cal  1 of chapatti two time/day 200k/cal  sabzi two times 300k/cal  1 glass milk given/day (120 k.calories)  boiled egg 80k.cal  boiled rice1 200k.cal  1 banana 110 k.cal Def: 430kcal/Day
  • 11.  1 time PCV transfusion  Hb 5.2 g/dl.  blood group O+ve.  blood was arranged from private laboratory.  Donor was cousin  blood transfused after proper blood grouping screening and cross match  No reaction was noted.
  • 12.  Hx was not Significant
  • 13.  ANTIMALARIAL  MULTIVITAMINS  SYP: BRUFEN  FOLIC ACID  ORAL ANTIBIOTICS  SYP: SILVER  SYP: OSNATE-D  SYP: DUPHALEC  SYP: MUCAINE  SYP: HIMALAYA
  • 14. 50yr Healthy 22y 45yr Healthy 25y married 5th DOL due to fits 6th DOL due to fits 17y 14y Pt; 9y NO Hx of chronic illness in family NO Hx of JAUNDICE in FAMILY
  • 15.  No any addiction or habit  Normal bowel habits  No any psychosocial problem  Student of class five  Home and school surroundings are satisfactory
  • 16. 7 family members Living in well built house Father is uneducated laborer by occupation earn 25-30k/month Source of water from hand pump water  NO Domestic animal at home.
  • 17.  patient daily activities have disturbed she is not able to continue his education, previously she has good education record  parents are disturbed financially and psychologically and worried about disease of his child because of repetitive opd visits.
  • 18. Parents have poor knowledge about disease they only know she has liver problem
  • 19.  A 12 ½ year old female child 5th issue of consanguineous marriage birth hx is unremarkable vaccinated developmentally normal admitted with c/o fever for 7days and abdominal distension for 6days associated with headache & fatigue and jaundice since july 2022. she has hx of hospital admission in July 2022 for 1 day with complaints of fever jaundice and pallor, transfused with PCV once at that time, and having multiple OPD visits b/c of fever jaundice and abd pain.  Death of two siblings in family in neonatal age with FITS  No h/o cough, glandular swelling, night sweats,rash, ear discharge, sore throat, joint pain, Burning micturation, diarrhea constipation, and bleeding from any site.
  • 21.  My patient is well looking, conscious and cooperative sitting on bed having obvious pallor with no obvious signs of respiratory distress and dysmorphic features having…  height 143 cm (at 75th percentile) and  weight 34kg (above 25th percentile)
  • 22. VITALS: R/R: 20 Br/Min H/R 104 Bt/Min TEMP 98.8f BP: 110/70 mmHg (systolic at 50th and diastolic below 50th percentile)  SEVERE ANEEMIA and JAUNDICE are present  NO koilonychia, Cyanosis, Clubbing, palmar erythema, nodes, Dehydration, bruises, petechie, discoloration, Pedal edema and Lymphadenopathy  Oral hygiene is satisfactory, ears, nose and eyes are normal there is no neck swelling,  BCG SCAR was PRESENT
  • 24.  Inspection Slightly Distended, moves with respiration, umbilicus is centrally placed with inverted margins, no visible marks/scars/pulsation/veins  Palpation  There was no tenderness Spleen = palpable 6cm below left costal margin with regular margins, smooth surfaces firm in consistency directed to RIF. LIVER, KIDNEYS, BLADDER OR ANY MASS WAS NOT PALPABLE Abdominal Girth: 60cm  Percussion Percussion note was dull on LUQ and in flanks regions, NO Fluid thrill but Shifting dullness was positive TOTAL LIVER SPAN WAS 8cm (upper border in 5th ICS)  Auscultation Bowel sounds audible
  • 25.  CNS is grossly intact,Hearing and vision intact,spine is normal.  Lung= Are clear Bilaterally  CVS: Apex beat is in 4th ICS, and JVP is not raised, S1 and S2 audible no added sound  MSK: no tenderness, swelling, discoloration, stiffness, or joint pain on passive movements  SMR: stage II
  • 26. A 12 ½ year old female child 5th issue of consanguineous marriage birth hx is unremarkable vaccinated developmentally normal admitted with c/o fever for 7days and abdominal distension for 6days associated with headache, fatigue and jaundice. she has hx of hospital admission in july 2022 for 1 day with complaints of fever jaundice and pallor, transfused with PCV once at that time, and having multiple opd visits b/c of fever jaundice and abd pain. Death of two siblings in family in neonatal age with FITS
  • 27.  O/E  well looking female child with average built and height, conscious and cooperative sitting on bed comfortably, vitally stable she looks pale and jaundiced NO koilonychia Cyanosis, Clubbing, palmar erythema, nodes, Dehydration, bruises, petechie, and Pedal edema and Lymphadenopathy. BCG SCAR WAS PRESENT Abdominal ex: slightly distended, non tender Spleen is palpable 6cm below left costal margin with regular margins, smooth surfaces firm in consistency directed towards RIF. LIVER, KIDNEYS, BLADDER OR ANY MASS WAS NOT PALPABLE Percussion note was dull on LUQ and in flanks regions, Shifting dullness is positive TLS is 8cm. bowels sounds audible Rest of systemic Ex: including CVS, CNS, CHEST AND MSK was UNREMARKABLE  SMR: stage-II
  • 29.  CHRONIC LIVER DISEASE 2NDRY T0… 1) Viral hepatitis? 2) Wilson disease? 3) Autoimmune hepatitis?  ABDOMINAL T.B?  MALIGNANCY?  HIV?  SLE?
  • 31.  HB 5.2g/dl  HCT 19.7%  MCV 53.3fl  WBC 4100/cmm  PLT 203000/cmm  MP-ICT… NEGATIVE  SMEAR… Microcytic hypochromic anisocytosis poikilocytosis
  • 32.  T. BILLI 15.7mg/dl  D. Billi 10.5mg/dl  SGPT 390 U/L  ALK PHO 479 U/L
  • 33.  Hepatosplenomegally  PV diameter 5mm  No free fluid seen
  • 34.  HB 6.2g/dl  HCT 22.4%  MCV 51.4fl  WBC 3000/cmm  PLT 91000/cmm  S. BILLI : 2.8mg/dl  DIRECT: 1.5mg/dl  SGPT : 159 U/L  ALK PHO: 604 U/L  MP-ICT P. VIVAX SEEN
  • 35.  HB 6.3g/dl  HCT 20.8%  RBC 3.78 millions/cmm  MCV 55.1fl  WBC 3700/cmm  PLT 70000/cmm  MP-ICT… NEGATIVE
  • 37.  T.Billi 2.0mg/dl  D.Billi 1.0mg/dl  SGPT 50U/L  ALK PHO 218U/L  PT 15sec  INR 1.07  APTT 36sec
  • 38.  RBS 106mg/dl  Urea 26mg/dl  Cre 0.7mg/dl  V/M NEGATIVE
  • 39.  Color.. Yellow  Appearance.. clear  pH.. 5.0  S gravity.. 1.015  Albumin.. nil  Sugar.. nil  Rbc.. Nil  Puss cells.. Nil  Epi cells 2-3/hpf
  • 40.  Coarse texture of liver  Suggestive of CLD  Mild Spleenomegally  Moderate ascites  PV diameter 10mm
  • 41.  Interpretation: WBC = 4700 HB = 7.2 g/dl HCT= 24.0 % RBC = 4.5 millions/dl MCV= 53.3 fl RDW= 32.1% MCHC= 30g/dl Plt=86000 SMEAR microcytic, hypochromic, anisocytosis and target cells RETICULOCYTES 1.0% NO blast
  • 44.  0.19 g/l  SLIGHTLY Below the reference range for age
  • 45.  ANA … POSITIVE  PATTEREN… COARSE SPECKLED  ASMA… NEGATIVE  AMA… NEGATIVE
  • 48.  INJ: CEFOTAXIME 1g i/v x 8 hourly  INJ: VIT:K 2mg diluted in 5cc i/v stat  Syp: Ibuprofen 200mg 2tsp x TDS  Syp: duphalec 30ml x HS  Syp: vidalyn 1tsp x OD  Syp: silver 1tsp x BD  Tab: aldacton 50mg ¾ x OD  Tab: inderal 10mg 1x OD
  • 49.  Tab: Deltacortil 5mg 4+0+3  Tab: HCQ 200mg 1xOD  Tab: Folic acid 1xOD  Tab: Aldacton 100mg ¾ x OD  Tab: Inderal 10mg 1xOD  Syp: Osnate-D 1+1  Syp: Mucaine 1xOD
  • 50.  natural history of disease  Complications of disease  Complications of drugs  Prognosis of disease with and without treatment  Avoid sun exposure  Regular follow up

Editor's Notes

  1. unevenful