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Case presentation on sle
- 1. Pokhara University School of Health and Allied Sciences Case Presentation on Systemic Lupus Erythromytous Presented By : Deepa Kumari Karn M Pharm (C.P), 4th Sem ClearkShip II
- 2. Pokhara University School of Health and Allied Sciences Contents • Patient Demographic Information • Complaints • Medical History • Medication History • Social History • Family History • Physical Examination • Laboratory Investigations • Drugs Information • Progress Chart/Investigations Others • Discharge Medications • Subjective Analysis • Objective Analysis • Assessment and Explanation • Planning • Refernces
- 3. Pokhara University School of Health and Allied Sciences Patient Demographic Information: Name Ashmita BK Age 16 Years Gender F Weight 39Kg Allergy Not Known Address Lekhnath, Kaski Contact Number 9806526125 Ward Medicine Date of Admission 23-03-2018 Date of Discharge 02-04-2018 Hospital No 74052844
- 4. Pokhara University School of Health and Allied Sciences Complaints Rashes in the face Swelling of B/L lower limbs × 4 days Fever × 1 days Complaints of hair loss and shortness of breath
- 5. Pokhara University School of Health and Allied Sciences Medical History Asymptomatic 4years Developed rashes around bilateral cheeks, increased rashes when exposed to sunlight initially itching too but now no itching. However 4 days prior developed swelling of B/L lower limbs, shortness of breath while laying down, fever for 1 days Photosensitivity
- 6. Pokhara University School of Health and Allied Sciences Medication History: • No past medication history and no history of hospital admission. Social History: • Good on study. • Non smoking history and non alcoholic Family History • No similar history or illness among siblings.
- 7. Pokhara University School of Health and Allied Sciences Physical Examination: General Fair CVS S1,S2, M0 RS B/L NVBS and no added sound CNS Grossly intact Others Normal Sleep, no multiple joint pain, normal appetite and bowel movement, no tender
- 8. Pokhara University School of Health and Allied Sciences Laboratory Investigations Test Value Range Test Value Range Urea 21mg/dl 13-43 Retics: 0.6% S. Cr 0.8mg/dl 0.6-1.1 Hb: 8.9gm/dl 11.7-15.5 Sodium 144mEq/l 135-146 PCV: 27.3% 40-50 Potassium 3.6mEq/l 3.5-5.5 MCV: 74fl 83-100 Alb 1.7gm/dl 3.5—5.2 MCH: 24pg 27-32 RBC 3.71×5×10×^6 /cumm 4.5-6 MCHC: 33% 31-35 Platelets 180×10^3/cumm 150-400 ESR: 58mm/hr <20 WBC 4.5×10^-3/cumm 4-11
- 9. Pokhara University School of Health and Allied Sciences Urine Analysis • Others – Rheumatoid Factor- Positive – USG- Hepatosplenomegaly Test Value Range WBC: 15-18/HPF <5 EP cells 2-3/HPF <15-20 RBC 3-4/HPF <5 Crystals Nill
- 10. Pokhara University School of Health and Allied Sciences Drugs Information S.N. Generic Name Dose Route F 1 2 3 4 5 6 7 8 9 10 Ranitidine Fexofenadine HCL Frusemide Prednisolone Hydrochlorothiazne Iron Azithromycin Frusemide Nebu A:I:N:S Fusidic Acid + Dexamethasone 150mg 120mg 20mg 20mg 200mg 1Tab 500mg 20mg P/O P/O I/V P/O P/O P/O P/O P/O IV topial BD HS TDS OD OD OD OD BD 6hrly BD
- 11. Pokhara University School of Health and Allied Sciences Progress Chart/Investigations Others Day -1 • B/L pitting edema, PR: 60bpm, RR: 22/min, BP: 80/60, flap -, fever-, nausea- , vomiting- Day- 4 • PR: 65bpm, RR: 22/mim, BP: 120/70mmHg, Temp: 98.6°F .
- 12. Pokhara University School of Health and Allied Sciences Day -9 • PR: 65bpm, RR: 22/min, BP: 120/70mmHg, Alopecia +, photosensitivity+, Renal Biopsy done and dermatological consultation was done Day- 10 • PR: 64bpm, RR: 22/min, BP: 100/70mmHg, Temp: 98.6°F, Renal Biopsy Report: No collection visualized in perirenal space
- 13. Pokhara University School of Health and Allied Sciences Discharge Medications 1. Tab ranitidine 150mg P/O OD 2. Tab prednisolone 10mg P/O OD 3. Tab Hydrochlorothiazide 200mg P/O OD 4. Iron Tab 1 tab P/O OD 5. Fusid B cream 6. Ray Shlolod cream SPF 50++ 7. Dermoist Creame BD
- 14. Pokhara University School of Health and Allied Sciences
- 15. Pokhara University School of Health and Allied Sciences Subjective Analysis Rashes in the face Swelling of B/L lower limbs × 4 days Fever × 1 days Complaints of hair loss and shortness of breath and photosensitivity
- 16. Pokhara University School of Health and Allied Sciences • The current symptom could be of systemic lupus erythromytous and upon examinations she was finally diagnosed with the Systemic Lupus Erythromyus
- 17. Pokhara University School of Health and Allied Sciences Objective Analysis • On clinical examination, – Molar rash, – Protein urea, – Blood Disorder – Photosensitivity
- 18. Pokhara University School of Health and Allied Sciences • She had BP of 80/60mmHg, PR of 82/min, Rheumatoid factor positive, bilateral pitting pedalodema was also found on day 1 and day 4 examination • Renal biopsy was done on day 9 and no collections was visualized in perirenal space
- 19. Pokhara University School of Health and Allied Sciences Assessment and Explanation • SLE is multisystem connective tissue disease • Inflammatory autoimmune disorder characterized by auto antibodies to nuclear antigens which can affect multiple organ systems • The severity may vary from a mild episodic disorder to a rapidly fulminant, life-threatening illness
- 20. Pokhara University School of Health and Allied Sciences Image Source: http://www.mcvitamins.com/causes%20of%20neuropathy/lupus- neuropathy.htm
- 21. Pokhara University School of Health and Allied Sciences • Factors: – Gender, – Race, – Genetic inheritance – Drugs (Procainamide, hydralazine, and isoniazide ) • Before making a diagnosis of SLE, it is imperative to ascertain that the condition has not been induced by a drug
- 22. Pokhara University School of Health and Allied Sciences Diagnostic criteria of SLE Malar Rash Discoid Rash Serositis Oral ulcers Arthritis Photosensitivity Blood disorders Renal involvement Antinuclear antibodies (ANAs) Immunologic phenomenon Neurological Disorder 4 out of 11 criteria conform SLE
- 23. Pokhara University School of Health and Allied Sciences Drugs Used Causes Hydroxychloroquine Helpful in treating lupus rashes or joint symptoms and appear to reduce the incidence of severe disease flares Given to the patient at a dose of 200mg OD. Prednisolone Control the inflammations and suppresses the immune system by reducing the production of lymphocytes and eosinophils Given at a dose of 20mg OD
- 24. Pokhara University School of Health and Allied Sciences Fexofenadine Reduces or block the release of histamine and thus reduces the allergic reaction to appear Relieve allergic symptoms such as itching, runny nose that was appeared in patient Frusemide loop diuretic which inhibits the reabsorption of sodium and chloride from the loop of henle and reduces the oedema To reduce the oedema furesemide 20 mg was given. Azithromycin WBC count in urine was increased that may show that the there is bacterial urinary tract infection and as a prophylaxis Azithromycine was given which is the widely distributed to the most of the cell of the body including WBC.
- 25. Pokhara University School of Health and Allied Sciences Tab Iron Haematological alterations such as anemia, neutropenia and thrombocytopenia are frequent in (SLE) Patient was also prescribed with iron tablet P/O OD Tab Ranitidine Competitively blocks histamine at H2 receptors of gastric parietal cells which inhibits the gastric acid secretion Ray Shoiold SPF 50++ and fusid B cream Developed the photosensitivity and to prevent and protect from the sunlight
- 26. Pokhara University School of Health and Allied Sciences • Management goals in patients with SLE include the early diagnosis and appropriate therapy whilst preserving overall kidney function without undue side-effects. • In order to realize such goals, it is clear that a kidney biopsy is essential in establishing diagnosis and prognosis, and guiding treatment. • In this patient the renal biopsy was performed on day 10 which showed no any collection in the peri renal space.
- 27. Pokhara University School of Health and Allied Sciences PLANNING • Prior to discharge all the investigations were rechecked which were improved • Patient was properly informed about that knowledge and was prescribed with appropriate medication on discharge with proper counseling • Instructed to follow up after 1 week in the OPD department.
- 28. Pokhara University School of Health and Allied Sciences References • Boon NA, Colledge NR and Walker BR (2006)Davidson’s Principles and practice of Medicine (20th Ed) Churchill Livingstone,1132-1134. • Shaifie KT, Shirwai AA, Samir N (2014) A Possible Case of Systemic Lupus Erythematosus Presenting with Generalized Edema, Medical Journal,14(4),581.584. • DIMS Nepal • https://www.ncbi.nlm.nih.gov/pubmed/19412194 (Assessed on 6th June 2018) • https://www.webmd.com/lupus/lupus-photosensitivity-uv#1 (Assessed on 6th June 2018) • https://emedicine.medscape.com/article/330369-treatment (Assessed on 6th June 2018) • https://academic.oup.com/ndt/article/21/7/1749/1821968 (Assessed on 6th June 2018)
- 29. Pokhara University School of Health and Allied Sciences