18 year old female with facial puffiness and pedal edema since one and half months

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Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. 



This E log book also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box is welcome.

C/o facial puffiness and pedal edema since one and half month 
Loose stools on and off since 1 month
Decreased urine output since 1 month

PT was apparently asymptomatic 6 yrs ago when she developed rashes over Malar area and abdominal pain , and c/o joint pains ( RT elbow ) f/b knee , ankle .
No h/o swelling redness 

H/o on and off fever ( 2-3 months ) , intermittent ,high grade, for which she as admitted . 
ANA + , dsDNA + , histone + , ribo p + , fundoscopy : anemic retinopathy 

Renal biopsy was done which showed lupus nephritis class 4 GA , was diagnosed with sle with lupus nephritis class 4 and was started on euro lupus regime - inj cyclophosphamide 500mg every 15 days X 6 months , t wyslone ( 8 months ) , inj methyl prednisolone X 3 days 

After which she was fine till 6 yrs AND SHE WAS OFF ALL MEDICATIONS SINCE LAST SIX YEARS 

 6 months ago she developed fevr + rash + arthritis ( reactivate lupus ) + episodes of loose stools on and off . C/o facial puffiness since one and a half month associated pedal edema and decreased urine output since one month


PT is on t . Clonidine 100mcg tid 
T.hcq 400 od
T.ramipril 5mg od ( 8pm ) since 20 days 

Not a k/c/o DM HTN ,cva , TB , epilepsy 

O/e : pt is c/c/c 
Pallor - absent , icterus - absent , lymphadenopathy - absent , clubbing - absent 

S /e : CVS - S1 S2 +
Rs - bae + 
P/a- soft,non tender
CNS -no FND

Investigations 

Hemogram - 
Hb - 6.4
Eosinophils -00
PCV -18.6
MCV -71.6
MCH -24.6
Rbc -2.6 mill/cumm

Aptt - 32secs

PT - 1.6 secs
INR - 1.11

Cue - 
Alb - 2+
Pus cells -3 to 4 
Epi cells - 2 to 3

Rft - 
Urea - 224
Uric acid - 13.0
Creatinine - 7.5
Ca - 7.3
Phosphorus - 8.1

Lft - 
TB - 1.13
DB - 0.35
Tp - 5.0
Alb - 2.1 

Abg 
pH - 7.29
Pco2 - 16.9
Po2 - 101
Hco3 - 8.0

Urine sodium -40
Spot urine protein - 315
Spot urine creatinine - 147.7
Ratio - 2.13




Treatment : 
Salt restriction <2g/day
Fluid restriction < 1.5 l/ day
T.hcq 400mg od
T.ramipril 5mg od
T.arkamine 100mg tid
Inj nahco3 100meq / IV / stat in 100ml NS
T.pan 40mg po/od
BP/ pr / temp charting
Strict I/o charting
Inj methyl prednisolone 500mg IV slowly infusion over 30mins od X 3 days 


Day 2 : 

Decreased urine output

PT is c/c/c

Pr 72 bom
BP 140/100mmhg
CVS S1 S2 +
CNS no FND
Rs - bae + 
P/a - soft, non tender 

I/o :300/500

Investigations 
Abg :
pH - 7.28
Pco2- 18.5
Po2 -121
Hco3 - 8.5
St.hco3 - 11.4

Blood urea - 188
Sr. Creatinine - 7.3

Sod - 143
K - 4.6
Cl - 106

USG abdomen - impression 
1. B/l grade 2 rpd
2. Mild pericardial effusion 
3. B/l pleural effusion 
4.mild ascites 
5. No renal artery and renal vein stenosis 

Treatment:
Same treatment plus t.nodosis 500mg po/tid and inj optineuron 1 amp in 100ml NS 

Day 3 
No fresh complaints 

PT is c/c/c 
Pr - 74bpm
BP - 150/90mmhg 
Cvs - S1 S2 + 
CNS - no FND 
Rs - bae + ,NVBS + 
P/a - soft , non tender 
Grbs - 178 

I/o - 800/1000ml

Investigations : 
Na -135
K - 5.1
Cl - 106

Sr creatinine -8.2
Blood urea - 257

Abg - 
pH - 7.27
Pco2 - 17.4
Po2- 101
Hco3 - 7.9
Sr.hco3 - 10.7

Treatment : same treatment given

Day 4 : 
No fresh complaints 
PT is c/c/c

Pr - 64bpm
BP - 150/90mmhg
CVS S1 S2+ 
Rs - bae+ , NVBS + 
P/a- soft, non tender 
CNS - no FND 

I/o - 800/550ml 
Grbs - 156 


Abg 
pH - 7.27 
Pco2 -23.1
Po2 - 115
Hco3 - 10.3
St.hco3 - 12 .5

Urea - 274
Creatinine - 7.4

Na - 132
K - 5.8
Cl - 110

Hemogram 
Hb - 6.3
Tlc - 6000
Plt - 1.14 

K - 5.2

Treatment - same treatment given

Day 5 


No fresh complaints 
Pt is c/c/c
Afebrile to touch 
PR - 72 bpm
BP -150/110 mmhg
CVS - S1S2 heard 
RS- BAE + 
P/A - soft ,non tender 
CNS - no FND 
GRBS - 154mg/dl @8:00 am 
I/O - 1300/450ml

ABG- PH - 7.33
          PCO2- 23.3
          PO2- 48.1
          Hco3- 12.1
          St.Hco3- 14.2 
          O2 sat - 77.9

Blood urea -298 increased from 274
Sr.creat - 8.7 increased from 7.7
Sr.electrolytes
   Na - 136
   K - 5.0
   Cl - 102

Treatment : same treatment given

                           BP trends
                      Respiratory rate trends 
                  Potassium trends 


Diagnosis : lupus nephritis stage 4 

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