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1. A Case study on Systemic
lupus erythematosus
09408103
Pharm.D (V year)
Clerkship
20-12-2013

2. CASE STUDY ON SLE
A 45 years female patient was admitted in the hospital on
DECEMBER 16th ,2013.
CHIEF COMPLAINTS:
C/O cough with sputum production for past 8 days.
H/O fever on and off for 5 days.

3. • HISTORY OF PRESENT ILLNESS:
• The patient is a K/C/O systemic lupus erythematosus and was
on treatment for the past 2 years and was on regular follow up.
• She was admitted for fever on and off for the past 5 days .
• She has cough with yellowish sputum for the past 8 days.
• She has an H/O photosensitivity and dental caries.
• Malar rashes

4. But she does not have a H/O throat pain, burning micturition,
joint pain or exacerbation of skin lesions, oral ulcers, chest
pain or headache.
• PAST MEDICAL HISTORY:-
She has burning sensation in eyes, SLE
• PAST MEDICATION HISTORY:
She was given methyl prednisolone (500mg in 5% dextrose)
pulse therapy during her last admission.

5. • PERSONAL HISTORY:
• Insomnia is present
• She is taking mixed diet and there is no loss of appetite.
• Normal bowel and bladder habits
• FAMILY HISTORY:
• Nothing significant

6. • PHYSICAL EXAMINATION:
A. GENERAL EXAMINATION:
Temperature : 101F (↑)
Pulse rate : 80 beats /min
Respiratory rate : 22 breaths / min
Blood pressure : 100/ 80 mmHg

7. • B. SYSTEMIC EXAMINATION:
CVS : S1, S2 +
CNS : NFND
RS : NVBS +, No added sounds
ABDOMEN : Soft

8. • DERMATOLOGICAL EXAMINATION:
• Scalp: Female pattern hair loss and thinning of scalp hair.
Erythematous plaque present in vertex.
• Face: Well defined erythematous plaques are present with
surrounding hyperpigmentation in neck ‘v’, trunk and back.
• Oral cavity: Curdy white plaques are present on the dorsum of
the tongue.

9. • Upper Limbs: Similar lesions are seen on the dorsum of hand
extensor aspect of upper limb.
• Lower Limbs: Well defined erythematous plaques are seen on
the medial aspect of left leg.
• Nails: Onycholysis in the right ring finger. Anonychia in the
left forefinger.

10. LAB INVESTIGATIONS
S.NO PARAMETER VALUE NORMAL
RANGE
1 ALBUMIN 7.2g/dl 3.5-5g/dl
2 GLOBULIN 3.7g/dl 2.5-3.5g/dl

11. • DIAGNOSIS:
SYSTEMIC LUPUS ERYTHROMATOSUS

12. TRATMENT
DRUGS DOSE ROA FREQUENCY DURATION
TAB.
WYSOLONE
20mg P/O 1-0-1 2 days
TAB.
HCQ
200mg P/O 0-0-1 2 days
TAB.
NEXPRO
40mg P/O 1-0-1 2 days
TAB.
SHELCAL
500mg P/O 1-0-0 2 days
TAB.
DOLO
650mg P/O 1-0-1 2 days
TAB.
FLUCONAZO
LE
150mg P/O STAT 2 days

13. SOAP NOTES:
• Subjective:
The patient has cough with sputum production for past 10 days
and H/O fever on and off for 3 days.
• Objective:
DERMATOLOGICAL EXAMINATION:
• Scalp: Female pattern hair loss and thinning of scalp hair.
Erythematous plaque present in vertex.
• Face: Well defined erythematous plaques are present with
surrounding hyperpigmentation in neck ‘v’, trunk and back.

14. • Oral cavity: Curdy white plaques are present on the dorsum of
the tongue.
• Upper Limbs: Similar lesions are seen on the dorsum of hand
extensor aspect of upper limb.
• Lower Limbs: Well defined erythematous plaques are seen on
the medial aspect of left leg.
• Nails: Onycholysis in the right ring finger. Anonychia in the
left forefinger.

15. • Vital signs were found to be normal in this patient. But the
laboratory investigations showed variations in certain
parameters like:
• Albumin: 7.2 g/dl (↑)
• Globulin: 3.7 g/dl (↑)
Assessment:
The patient is diagnosed with ‘Systemic lupus erythematosus.’

16. Plan of Treatment:
The Patient was treated with Corticosteroids,
hydroxychloroqine, Proton pump inhibitors, calcium
supplements, Antibiotics & NSAIDS.

17. PATIENT COUNSELLING
• Strictly adhere to the drug regimen.
• Avoiding sunlight is the primary change to the lifestyle
• Occupational exposure to silica, pesticides and mercury can
also make the disease worsen.
• Don’t stop any drug when feeling better.
• Report to the physician if you experience any adverse effects.
• Eat a healthy diet. A healthful diet is one that is low in
saturated fat and rich in whole grains, fruits and vegetables.