20 year old female with Lupus Nephritis

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Sanidha Singh

206

A 20 YEAR OLD FEMALE CAME TO THE OPD WITH COMPLAINTS OF HEADACHE, VOMITING, NECK STIFFNESS SINCE 5 DAYS.

CHIEF COMPLAINTS :

Headache since 5 days 

Vomiting since 5 days 

Neck stiffness since 5 days 

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 months back then she came to our hospital with complaints of 

* swelling over the ankle on both legs 

* hyperpigmented macules 

* fever , cough , SOB

* decreased urinary output and loss of ability to speak 

Based on the above symptoms she was evaluated and was diagnosed with SLE and was treated accordingly based on the symptoms and once the symptoms were relieved she was discharged.

She again came to the hospital 3 days back with complaints of headache, neck stiffness , vomiting.

Headache- dragging type with neck stiffness which was present throughout the day.

Vomiting- 3 to 4 episodes of vomiting was present after consuming food which was non projectile, non bilious with food as content and is not associated with pain or abdominal discomfort.

No h/o fever, blurring of vision, trauma.

PAST HISTORY: 

 No history of diabetes, hypertension, asthma , tuberculosis , epilepsy.

FAMILY HISTORY;

No significant family history.

PERSONAL HISTORY:

Diet- mixed 

Appetite- normal

Sleep- adequate

Bowel and bladder- regular 

GENERAL EXAMINATION: 

Patient is conscious,coherent,cooperative and well oriented with time,place,person.

She is moderately built and nourished 

Pallor is present 

Facial puffiness is present with stary look

Previous rashes susbsided

No signs of clubbing,cyanosis,generalised lymphadenopathy 

Vitals: 

Temperature- Afebrile

Pulse rate- 76bpm

BP- 140/100mmHg

RR-16cpm

GRBS-140mg/dl

On local examination: 

CNS: 

HIGHER MENTAL FUNCTIONS:

Conscious, oriented to time place and person.

MMSE 30/30

Memory : Intact.

Intelligence : Normal

Lobar Functions : No hallucinations or delusions.

CRANIAL NERVE EXAMINATION:

1st : Normal

2nd : visual acuity is normal

           visual field is normal

            colour vision normal

            fundal glow present.

             

            Diplopia is present.

3rd,4th,6th : pupillary reflexes present.

                      EOM full range of motion present

5th : sensory intact

                      motor intact

7th : normal

8th : No abnormality noted.

9th,10th : palatal movements present and equal.

11th,12th : normal.

MOTOR EXAMINATION: 

                     Right                              Left

                     UL       LL                 UL      LL

   BULK  Normal Normal   Normal Normal

   TONE  Normal Hypotonia Normal Hypotonia

   POWER      5 /5            5 /5               5/5          5/5

   SUPERFICIAL REFLEXES:

CORNEAL present                          present       

   DEEP TENDON REFLEXES:

                                          R       L

   BICEPS                           +.    +

   TRICEPS                        +.    +

   SUPINATOR                  +.  +

   KNEE                               +. +

 

   ANKLE                            +.  +

    

SENSORY EXAMINATION:  

SPINOTHALAMIC SENSATION:

Crude touch:present

pain:present

temperature: N. N

DORSAL COLUMN SENSATION:

Fine touch:present

Vibration:present 

Proprioception:present

CEREBELLAR EXAMINATION:

  Finger nose test: co ordination present

  Heel knee test: present 

  Dysdiadochokinesia- negative

  Speech:absent 

GAIT: normal

Abdomen:soft,non tender no organomegaly

CVS: s1,s2 heard no added murmurs

Respiratory:bilateral airway entry is present,vesicular breath sounds heard

PROVISIONAL DIAGNOSIS:

Lupus nephritis

INVESTIGATIONS:

Blood Urea done on 2/12/22:

Blood Urea done on: 4/12/22

MRI BRAIN done on 2/12/22:

USG Report done on 1/12/22: 

TREATMENT:

On 1-12-2022

Tab paracetamol 500mg PO TID

Tab warfarin 5mg PO BD

Tab Hydroxychloroquine 200mg PO OD

Tab azathioprine 50mg PO BD

Inj zofer 4mg iv BD

Tab prednisolone 20mg PO OD, 10mg PO OD

Syrup sucralfate 15ml PO BD

On 2-12-2022

Tab paracetamol 500mg PO TID

Tab warfarin 5mg PO BD

Tab Hydroxychloroquine 200mg PO OD

Tab azathioprine 50mg PO BD

Inj zofer 4mg iv TID

Tab prednisolone 20mg PO OD, 10mg PO OD

Tramadal -1 amp IV

Normal saline -100ml IV

Syrup sucralfate 15ml PO BD

Injection mannitol-

100 ml IV

Injection monocef, trenexamic acid 2gm, injection vitamin K. 10 mg IV OD

On 3-12-2022

Tab paracetamol 500mg PO TID

Tab warfarin 5mg PO BD

Tab Hydroxychloroquine 200mg PO OD

Tab azathioprine 50mg PO BD

Inj zofer 4mg iv TID

Tab prednisolone 20mg PO OD, 10mg PO OD

Tramadal -1 amp IV

Normal saline -100ml IV

Syrup sucralfate 15ml PO BD

Injection mannitol-15 mg 

Dexamethasone -8mg IV TID

on 5-12 -2022

1.IV FLUIDS -NS

2.Inj MONOCEF 1gm IV BD

3.Inj PAN 40mg IV OD

4.Inj ZOFER 4mg IV TID

5. Inj DEXA 8 mg IV TID

6. Tab DOLO 650 mg PO TID

7. Tab HCQ 200mg PO OD

8. Tab AZATHIOPRINE 50 mg PO BD

9. Inj MANNITOL 20 gm IV TID

On 6/12/22

Inj MONOCEF 1gm IV BD

Inj PAN 40mg IV OD

Inj ZOFER 4mg IV TID

Inj DEXA 8 mg IV TID

 Tab DOLO 650 mg PO TID

Tab HCQ 200mg PO OD

Tab AZATHIOPRINE 50 mg PO BD

Inj MANNITOL 20 gm IV TID