2. Patient Name -XXX
Weight - 56kgs, Height - 158 cms
with c/o Sadness: 3months
Fever : 2 months
Malar rash : 45 days
Headache : 45 days
HISTORY OF PRESENTING ILLNESS:
* Patient with sadness ,low mood , loss of interest, decreased
sleep , suicidal tendency for 3 months
* Patient was apparently asymptomatic 2 months back when
she developed fever associated with generalized body pains,
rash on palms, back and arms, joint pains, anorexia,
sleeplessness and headache.
* Patient presented to a local hospital, treated
symptomatically, fever was relieved on medication and was
discharged. 10-15 days later she developed malar rash, and
persistent fever. Then, she rushed to KIMS hospital with
fever and malar rash.
4. HISTORY OF PRESENTING ILLNESS:
Fever was intermittent, low grade, on and off, no
chills/rigors, associated joint pains mostly involving large
joints [non migratory and non-fleeting] From day-1 of
fever, she developed macular erythema on palms, upper
back and extensor aspect of arms and 10-15 days later she
developed malar rash, which is slightly raised
erythematous rash on cheek and nose, precipitated by sun
exposure and non-pruritic.
No s/o purpuria , no oro-genital eruptions or scaly lesions
on another part of the body.
No h/o DM/HTN/TB/Asthma/Epilepsy. Mother expired 3
months back. Feels guilt and herself responsible for the event
married since 1 year
No past h/o exposure to c/o TB, mite bite, tick bite, or exposure to
rats or cats.
No history s/o malaria, chikungunya, dengue, typhoid.
No history of visual disturbances, altered sensorium & no
complaints s/o motor or sensory impairment No h/o cough or
dyspnea No history of drug allergy No h/o similar complaints in the
No f/h/o DM, HTN, ASTHAMA, TB
H/o Frequent quarrel with husband
H/o Skipping meals
H/o Crying always at home
H/o Suicidal tendency
Interpersonal problems with her
husband and mother-in-law
6. PERSONAL HISTORY:
Diet-Mixed; Appetite-Decreased; Sleep-Decreased
Bowel-Regular; Bladder-Normal; Habits-None
Menstrual history-menarche at 13, cycles regular,
4/30, no dysmenorrhea, no clots. No similar
complaints in the family
PHYSICAL EXAMINATION :
Patient is conscious, coherent, cooperative,
comfortably sitting on bed, well oriented to time,
place & person. Normal hair Malar rash on face
,macular erythema on palms and back, non-discoid,
non-bleachable. No oro-genital ulcers.
7. Eyes appear normal. O/e URT normal. No
congestion or secretions noted
BP - 110/80mmHg
RR - 16cpm
P[+], I[-], C[-], C[-], L[-], E[-]
PR - 80 bpm
Temp- 100 F.
8. SYSTEMS :
P/A - soft ,no tenderness, no organomegaly, BS+
RS- NVBS+, no Adv sounds
CVS - S1,S2 heard, no murmurs
Muskulo-skeletal system examination-no swelling or redness or
tenderness over large or small joints, no limitation of movements at
joints, no pain, no stiffness
PROVISIONAL DIAGNOSIS :
? Connective tissue disorder
? Granulomatous disease
? Enteric fever
9. LABORATORY INVESTIGATIONS
Total leucocytes counts
Bl. U (mg/dl)
Sr. Cr (mg/dl)
Ep: 1-2 cells
Up to 0.4 mg/dl
Up to 120iu/L
3.5-5 .5 gm/dl
Ep: 1-2 cells
Up to 103 mEq/L
Normocytic normochromic, leucopenia,
Dengue card& serology
Anti ds DNA Antibodies-
Positive (233 iu/ml)
Based on the subjective & objective evidence the
patient was diagnosed to have SYSTEMIC
LUPUS ERYTHEMATOSIS with DEPRESSION
13. GOALS OF TREATMENT
To prevent recurrence (depression)
Eliminate depression with complete remission of
Treatment include management of acute and chronic
Goals are preventing progressive loss of organ
function, minimizing disease disabilities, preventing
complication from therapy.
14. MEDICATION CHART
MEDICINE ON DISCHARGE
MEDICINE ON REVIEW DT: 16/12/13
15. PROGRESS NOTE:
From Day-1 to 3:
Patient was feeling better from Day-3.
Patient was discharged and advised to take
Azathioprine 5omg, Clonazepam 0.5mg and
Prednisolone 40mg for 2 weeks.
At Review on 16/12/13:
Patient cell count improved, rash faded
comparatively, but complained alopecia, GI
symptoms. Patient was to take Prednisolone 40mg
bd, Azathioprine50mg bd, Pantoprazole 40mg bd
and Escitalopram 10mg bd.
Suggestion to PhysicianSLE
• No drug interaction is found.
• Methyl Prednisolone would have been given 1g i.v for
every 3 days instead of consecutively for 3 days.
• Iron supplements might have been added in the
prescription, since patient is anemic.
• Antipyretic/Analgesics would have been advised for
symptomatic relief for patient’s feel better.
• At least on review, MVI&MM might have been advised, as
Patient was c/o alopecia.
• No suggestion is required to be given in this regard.
17. Advice to patientSLE
• Adhere to medication.
• Maintain hygiene.
• Regular follow-up.
• Drink plenty of water.
• Consume fresh fruits and vegetables.
• Avoid exposure to sunlight or artificial UV light.
• Seek medical attention immediately, if exacerbations occurs.
• Take more protein containing foods like beans, nuts, peas.
• Co-operate with the Physician till remission of treatment/ Diagnosis
• Take orange juice and iron rich foods like chicken, meat, egg and
green leafy vegetables like spinach and beetroot.
• Family has been advised to arrange Counseling, Couple-focused
therapy, Family therapy, Hypnotherapy, Music therapy, Behavioral
activation and interpersonal therapy is recommended as a
treatment option for patients with depression