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Current admission
2nd admission on 6-2-2023
29 year old female who is a customer service executive by occupation, came to the hospital with chief complaints of vomitings since 3 days and loose stools since 3 days.
HOPI:
Patient was apparently asymptomatic 3 days ago, then she developed loose stools since 3 days (3-4 episodes/day) , watery in consistency and not associated with fever and pain abdomen. Complaints of vomitings since 3 days (2-3 episodes/ day) which were yellowish and contained food particles, non projectile, not blood stained.
Past history:
3 months ago she got admitted in our hospital with complaints of sudden worsening of SOB and was diagnosed with acute cardiogenic pulmonary edema with immune mediated glomerulonephritis and seizures secondary to ?PRES /? Uremia /? Vasculitis.
Known case of SLE with lupus nephritis since 2 months and is on
Rabeprazole + domperidone
Tab orofer xt po/od 8am
Tab shelcal 500mg po/od
Tab sodium bicarbonate 500mg po/bd
Tab nicardia 20mg po/tid
Probiotics
She’s not a known case of diabetes, hypertension, CAD, asthma, tuberculosis.
Personal history:
Appetite :lost
Diet: vegetarian
Bowels : loose stools since 3 days
Micturition: normal
No addictions
General examination:
Pallor: present
No icterus, cyanosis, clubbing, lymphadenopathy, oedema of foot.
Vitals:
Temperature: 98.2 F
Pulse rate: 131bpm
Respiratory rate: 24/min
BP: 180/110mmhg
Spo2: 98%
GRBS: 98mg/dl
Systemic examination
CVS:
S1 ,S2 present
No murmurs
Respiratory system:
Bilateral air entry present
Normal vesicular breath sounds heard
No dyspnoea and no wheeze
Per abdomen:
Shape of abdomen: scaphoid
Tenderness present around umbilicus
Liver and spleen are not palpable
CNS:
Patient is conscious
Speech: normal
Cranial nerves: normal
Motor and sensory system: normal
Glassgow coma scale: E4 V5 M6
Diagnosis
Acute Kidney Injury with Lupus Nephritis secondary to acute gastroenteritis (resolved) with hyperkalemia (resolved) with ?anemia of chronic inflammation with ? Lupus induced heart failure with pulmonary edema(resolved)
K/c/o HTN since 3 months
2 PRBC Transfusions done
4 Sessions of hemo dialysis done
Inj.Pan 40 mg IV/OD BBF
Inj. Zofer 4mg IV/SOS
Inj. Lasix 40 mg IV/TID
T. Wysolone 40 mg PO/OD
T. Nicardia 30 mg/20mg/30mg
T.HCQ 200mg PO/OD
T.Azathioprine 50 mg PO/OD
T.MET-XL 25mg PO/OD
Syp.Sucralfate 10 ml TID Before food
Prevous admission credits- https://rishithareddy30.blogspot.com/2022/11/30-yrs-old-female.html?m=1
30 years old female presented to casualty with
chief complaints of sudden worsening of SOB since one day
History of presenting illness:
patient was apparently normal till six years back in 2017 she had generalised body aches and joint pains which involves multiple large joints of which elbow And knee joints troubled her associated with generalised body aches after multiple hospital visits
she even noticed hair loss without scarring and oral ulcers then she was diagnosed with autoimmune disorder and initiated on hydroxychloroquine azathioprine wysolone
she reported that her joint pains and hair loss was not improving with the above medication she had multiple hospital visits and admissions for joint pains and body aches which bothers her from doing her activities .
Two months back she had pedal edema two months back she had pedal edema sudden onset shortness of breath initially on exertion then she was diagnosed with hypertensive emergency admitted and discharged with antihypertensive . patients stopped AZA as advised by doctor except hyper antihypertensive since yesterday she had shortness of breath initially on exertion which rapidly progressed to sob at rest
No small joint pains no colour change /paraesthesia so fingers on exposure to cold
New onset of seizures :Patient had one episode of involuntary movements initially started left-hand followed by total body with impaired consciousness no tongue bite no involuntary maturation or defecation yesterday
Personal history:
daily routine a day starts at 7 AM after breakfast work starts from 9 AM attending client calls with 1 to 2 breaks in between till 6 PM more of sedentary work
Diet - mixed
Appatite-loss of appetite
Sleep- adequate
Bowel and bladder - regular
No Addictions
Past history :
Two months back she had pedal edema two months back she had pedal edema sudden onset shortness of breath initially on exertion then she was diagnosed with hypertensive emergency admitted and discharged with antihypertensive since 10 days .
Patient got dialysis done three times one month back
Insertion site : femoral region
O/e:
Patient conscious coherent cooperative
BP presentation to 220/140 MMHg given NTG and Nicardia ___BP-160/100 MMHg
PR-134bpm
RR-36cpm___24cpm
SpO2-236mg/dl
GRBS-236mg/dl
General physical examination :
Pallor present
flat nails
non-scarring alopecia
hyperpigmented discoid rashes on face Periauralblack discolouration of oral mucosa and palate
Mild pedal edema
CVS :
no raised JVP
S1 S2 +
no murmurs
RS:
BAE +
diffuse inspiratory and expiratory crepts
P/A:
Soft and non-tender
mild distended
umbilicus inverted
no organomegaly
CNS:
HMF intact
E4V5M6
Pupils NSRL
no FND(last seizure episode )
Labs :normocytic normochromic anaemia with leukocytosis
Diagnosis :
ACUTE CARDIOGENIC PULMONARY EDEMA with Immune mediated Glomerulonephritis.
SEIZURES SECONDARY TO ?PRES/?Uremia/? vasculitis.
Rx:
1.Inj. LEVIPIL 500mg IV TID
2.INJ.NTG 50 mg in 50 ml NS @5ml/hr to maintain SBP-<160mmhg
3. INJ.LASIX 40mg IV BD
4.TAB.NICARDIA RETARD 20mg PO BD
5.TAB.OROFER -XT PO/OD
6. Tab.HCQ 200mg PO BD
7.fluid and salt restriction
8. Monitor vitals and inform sos
9.INJ.HAI S/C acc to GRBS inform ICU /PG@ 7 point profile GRBS
10. Strict I/O Charting
11.TAB.MET XL 25mg PO BD
12. TAB.TELMA 40 mg PO/OD
13.TAB .WYSOLONE 20mg /PO/OD
