Upload
amlendra-yadav
View
145
Download
6
Tags:
Embed Size (px)
DESCRIPTION
case presentation of SLE with Nephritis
Citation preview
Welcome to Clinical Meeting
Presented by DR. Dhiraj Chandra Biswas DR. Amlendra K. Yadav Resident (phase-A)
Particulars of the Patient
Name : NUPUR Age : 10 years Sex : Female Address :
Noaokhali Reg. no. : 550/02 Date of Admission :18/06/2014 Date of examination :18/06/2014 Informant : Mother
Chief Complaints
Fever for 4 months. Pain over multiple Joints for same duration. Rash all over body for same duration.
History of Present illness
According to the statement of informant mother, her child was reasonably well 4 months back, then she developed fever which was high grade, intermittent in nature, highest recorded temperature was 1030F, not associated with chills and rigors but subsided after taking antipyretics.
Contd……………
She also developed pain over multiple joints which first appeared both knee joint followed by both ankle, both wrist, elbow and small joints of hand and feet. Pain was non-migratory in nature, associated with morning stiffness lasting for 10- 20 minutes.
Contd……………
She also developed rash all over the body for last 4 months which appeared first over cheeks, nasal bridge but spared the nasolabial fold, then on both upper and lower extremities, chest and abdomen which were non pruritic in nature. On query, mother gave h/o of red color urine and painless oral ulceration.
Contd…………… She had no history of joint swelling,
photosensitivity, hair loss, respiratory distress, abdominal discomfort, headache or convulsion.
For these above mentioned complain she was treated in Dhaka sishu hospital with NSAIDs, antibiotics, hydroxychloroquine and 2 unit blood transfusion 2 months back but condition did not improved.
Contd……………
As the condition of child did not improve she was referred to BSMMU for further evaluation and management .
Birth History Antenatal History: Mother was on regular Ante natal
check up.
Natal history: Delivered at term at home by NVD.
Postnatal History: Uneventful. Cried immediately after birth.
Immunization History Immunized as per EPI schedule.
Milestones of Development Age appropriate.
Feeding History On normal family diet .
Family History She is the 4th issue of her parents.
other family members are healthy .
Socio-Economical History
Belongs to low socio-economical background, father is a farmer, stay in kacha house and drinks tub-well water.
Physical ExaminationGeneral Appearance : Ill-looking. Pallor : Moderately pale Edema Jaundice Cyanosis Clubbing Absent Koilonychias Dehydration
Neck vein : Not engorged
Lymph Node :- Not enlarged
Skin survey : – BCG scar mark present. Erythematous rash present over cheeks and nasal bridge sparing nasolabial fold and some blackish rash on both upper and lower extremities, chest and abdomen which are non palpable and does not blanch on pressure.
Signs of meningeal irritation : – Absent.
Bony tenderness : – Absent
Bed side urine for albumin : Nil
Vital Signs Temperature – 101o F
H.R – 110 beats /min
B.P – 120/90 mmHg (lies above 95th centile)
R.R – 28 breaths /min
ANTHROPOMETRY:
Weight - 22 kg ( 3rd to 5th centile)
Height - 126cm ( 3rd to 5th centile)
Systemic Examination
Locomotor system Look: No swelling , no deformity or muscle
wasting, position of the limb normal.
Feel: Tenderness present (grade 2/4) over B/L knee joint ,ankle joint , elbow joint and meta-tarsophalengeal joint.
Move: Movement of all joint are restricted.
Other Systemic examination reveals normal
Gastrointestinal System
Oral cavity :– Multiple oral ulceration present. Abdomen :- Soft , not distended , non-tender,
umbilicus centrally placed & inverted,
Liver and spleen not palpable.
Shifting dullness absent.
Bowel sound present.
RESPIRATORY SYSTEM Inspection
• Shape of the chest : normal• R/R : 28 breaths/min• Visible vein & Pulsation : absent
Palpation• Trachea : centrally placed• Apex beat : left 5th ICS, medial to midclavicular line
Percussion note Resonant all over the lung fields
Auscultation Breath sound : Vesicular Added sound : Absent Vocal resonance : Normal & symmetrical
CARDIOVASCULAR SYSTEM
Inspection:• No visible pulsation
Palpation:• Thrill : Absent • P2 : Not palpable• Apex beat : left 5th ICS medial to midclavicular line• Lt. parasternal heave : Absent
Auscultation:• 1st & 2nd heart sounds audible in all 4 areas Murmur : Absent
Genito urinary system
Kidney – Both kidney not ballot able
renal angle – non-tender
Bladder – Not palpable
Salient Features
Nupur , 10yrs old female child 4th issue of non-consanguineous parent got admitted with a complaints of high grade intermittent fever and pain over multiple joints with Haematuria and oral ulceration for last 4 months . She also developed non-pruritic rash over face, trunk and extremities.
Salient Features contd………..
For that she had treated with NSAIDs , antibiotics, hydroxychloroquine and 2 unit blood transfusion but condition did not improved. She had no history of joint swelling, photosensitivity, hair loss, respiratory distress, abdominal discomfort, headache or convulsion
Salient Features contd………..
O/G/E- Patient was ill llooking, febrile, moderately pale, multiple painless ulceration present .
Skin survey : Erythematous rash present over cheeks and nasal bridge sparing nasolabial fold and some blackish rash on both upper and lower extremities, chest and abdomen which are non palpable and does not blanch on pressure.
Salient Features contd………..
Bed side urine for albumin= nil. Vitals: temperature 101o F, She is hypertensive. Systemic examination: Locomotors system
examination reveals arthalgia present. Other systemic examination- normal.
Provisional Diagnosis
???
Provisional Diagnosis
Systemic Lupus Erythematous (SLE)
Differential diagnosis
Systemic onset JIA
Point in favor Point against
SLE
• Female child• Fever • Arthralgia • Typical rash• Oral Ulcer• Hematuria• Hypertension
SOJIA
• Age less than 16 years • Intermittent fever • Arthralgia
No characteristics rash
INVESTIGATION
CBC Test Date 19/06/2014
Hb% 6.8 g/dl
ESR 10 mm in 1st hour
Total count of WBC 4500 cumm
Neutrophil 70%
Lymphocyte 27%
Platelet count 3,50,000 cumm
CRP < 6 mg/dl
Blood Group AB Positive
CBC
Test Date 19/06/2014
ANA Positive
Anti-ds-DNA 154.5 U/ml ( positive )
Coomb’s Test Positive
C3 level 0.093 g/l ( decreased )
C4 level 0.317 g/l ( decreased )
SGPT 24 U/L
S. Creatinine 0.6 mg/dl
Chest X-ray Normal Findings
On 21/06/2014
MT 02 mm
Blood culture No growth of bacteria
Urine R/M/E Pus cell – (6-7)/hpf RBC - (10-15)/hpf
Urine Culture No bacterial growth
UTP 0.94 gm/day
UTV 1200 ml/day
HBsAG Negative
PT 12.6 sec
APTT 41.6 sec
Final diagnosis
SLE with Lupus Nephritis
Management
Counseling: About the nature and future of the disease Renal Biopsy Diet
Drug therapy: IVF – 10% dextrose IV antibiotics ( Inj. Ceftriaxone ) Tab. Hydroxychloroquine Tab. Naproxen Tab. Ranitidine Tab. Paracetamol Tab. Calcium with Vitamin D Tab. Folic acid Tab. Captopril
Follow up
F/U On25.6.2014
Subjective Objective Assessment Plan
Fever still persistOral mucosal ulcer present
Ill- looking, mildly pale, FebrileRR – 24/minHR – 96/minBP – 90/60mmhgBSUA - Nil
Not improving Continue antibiotics & plan to start inj. Methylprednisolone and Inj. Amikacin
Subjective Objective Assessment Plan
No new complain(Fever subsided)
Well, allert , afebrile Vitals within normal limit BSUA – nil
Improving Started oral prednisolone and cyclophosphamide
F/U On 29.6.2014
Thank You..