A 45-year-old female patient with a history of systemic lupus erythematosus (SLE) was admitted to the hospital with a cough producing sputum for 8 days and fever for 5 days. On examination, the patient exhibited rashes, lesions, and nail abnormalities consistent with SLE. Laboratory tests showed slightly elevated albumin and globulin levels. She was diagnosed with SLE and treated with corticosteroids, hydroxychloroquine, proton pump inhibitors, and other medications. The patient was counseled on adherence to treatment, lifestyle changes like avoiding sunlight, and reporting any adverse effects.

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.