18year old girl came with chief complaints of fever since 2months back c/o joints pain since 2months back

This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. 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 patients 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 comment box is welcome

18year old girl came with chief complaints of fever since 2months back 

c/o joints pain since 2months back

c/o vomitings since 2months back for 1week,

c/o headache along with fever episodes since 2months

 c/o  pain abdomen since 5days back

HOPI :-

Patient was apparently asymptomatic 2months back ,then she developed fever following after fever subsides pt started having pain in the small joints PIP,DIP,MCP etc.subsides with medication and relapse after stopping the medication.now she has h/o fever a/w multiple joints pains (small joints of hands ---->elbow---->sho byulder). 

Patient had h/o migratory polyarthritis.

H/o dragging type of pain in my the both lower limbs (Ankle jnt& joints of foot are spared).

H/o decreased appetite since 2months .H/o pain abdomen (spasmodic type) since 5days back now subsides not associated with loose stools.

H/o vomitings since 2-3days ,non bilious,non projectile containing food particles.

H/o headache present , burning sensation in the eyes

PAST HISTORY

N/K/C/O DM,HTN ASTHMA, THYROID,TB

PERSONAL HISTORY:-

Appetite -decreased since 2months

Diet:-mixed

Bowel & bladder-regular

O/E:

Pallor +

No Icterus/cyanosis/clubbing/Generalized lymphadenopathy/pedal edema 

Temp-afebrile

PR- 83bpm

RR-18/min

BP-110/60 mmhg

Spo2- 98%at RA

GRBS-120 mg/dl

CVS- S1 S2 +,No murmurs

RS- BAE+,nvbs +

P/A- soft, non tender 

CNS- NAD

INVESTIGATIONS;-

Chest X ray

X ray of hands

USG

ECG

 Other

Serum LDH

Direct coombs test

PROVISIONAL DIAGNOSIS:-

FEVER WITH POLYARTHRITIS (SECONDARY TO RA?  OR  SLE?) UNDER EVALUATION

TREATMENT;-

1)T. ULTRACET (325MG+37.5MG)  PO/QID

2)T.ZOFER (MD) 4MG PO/SOS

3)T.ZINCOVIT PO/BD 

4)T.LIMCEE PO/BD

5)T.PAN  40 MG PO/OD

SLICC criteria for SLE:-

Discharge summary;-

14/02/22

S - C/o fever spikes . (102 recorded morning) . After that no spike

C/o - Multiple joint pains and left elbow mild swelling.

C/o loss of appetite and nausea.

C/o Erythematous rash on malar prominence and nasal bridge .

H/o vomitings and nausea after discharge on 7/2/22 - could be due to HCQ intolerance.

She used T. Onmacortil 10 mg for 2-3 days and stopped later due to vomitings.

HCQ, Aceclofenac stopped on 11/2/22.

C/o fever spikes since yesterday and joint pains .

Hemogram repeat today - 

Hb -7.2 ; Tlc - 4,880 ,plt -8,000

Cue - no proteinuria

s. creat -0.9 mg/dl

Cxr - No pleural effusion

Crp - Positive .

plan - to send dengue profile .

Pt vitals stable currently and no bleeding manifestations .

Oral ulcer:-

Malar rash

Investigation:-

Diag -

 SLE Flare ./ ? Viral pyrexia

Ana + ; Anti- ds DNA + ; Coombs -+ 

Fever and polyarthralgia 

Anemia and severe thrombocytopenia.(? Immune destruction) .

Query - Is this sle flare or secondary infection ?

General dictum if crp is positive - consider infections also.

Crp - negative - Treat as flare 

Treatment given : 

1) Tab . Dolo 650 mg QID

2) INJ DEXA 2MG IV BD 

3) Tab . Pan 40 od

4) Tab zofer 4 mg tid .

5) IVF - NS/RL .

The sensitivity and specificity of platelet autoantibody testing in immune thrombocytopenia: a systematic review and meta-analysis of a diagnostic test

The sensitivity of platelet autoantibody testing is low (53%). The specificity is high (> 90%).

https://onlinelibrary.wiley.com/doi/10.1111/jth.14419

The sensitivity of antiplatelet antibody in SLE patients with ITP is very low so that's the reason why we don't go for it usually

AMC 7

Day 4

S - No fever spike

No episode of vomiting and diarrhoea

C/o polyarthralgia decreased

O:-

O/E

Pt c/c/c

Pallor+ 

No icterus, cyanosis clubbing, lymphadenopathy, oedema

Temp;-96.8°F

Bp:-110/70mmhg

PR:-68bpm

RR:-16cpm

Hemogram repeat today - 

Hb -7.3 ; Tlc - 16,600 ,plt -48,000.

14/2/22

Hb -8.2

Tlc-4,500

Plt-8,000

15/2/22

Hb-8.7

Tlc-4,800

Plt-5,000

16/2/22

Hb-7.3

Tlc-12,550

Plt-25,000

17/2/22

Hb-7.3

Tlc-16,600

Plt-48,000

Pt vitals stable currently and no bleeding manifestations .

A:-

 SLE Flare .

Ana + ; Anti- ds DNA + ; Coombs -+ 

Fever and polyarthralgia 

Anemia and severe thrombocytopenia.(? Immune destruction) .

P: 

1)Inj.Methyl prednisolone 1g /iv/stat after faculty consultation

2) Tab . Pan 40 mg po/od

3) Tab zofer 4 mg /sos

4) IVF - NS/RL .

AMC 7

Day 5

S - No fever spike

No episode of vomiting and diarrhoea

C/o polyarthralgia decreased

O:-

O/E

Pt c/c/c

Pallor+ 

No icterus, cyanosis clubbing, lymphadenopathy, oedema

Temp;-97.4°F

Bp:-110/70mmhg

PR:-72bpm

RR:-18cpm

Hemogram repeat today - 

Hb -7.3 ; Tlc - 16,600 ,plt -48,000.

14/2/22

Hb -8.2

Tlc-4,500

Plt-8,000

15/2/22

Hb-8.7

Tlc-4,800

Plt-5,000

16/2/22

Hb-7.3

Tlc-12,550

Plt-25,000

17/2/22

Hb-7.3

Tlc-16,600

Plt-48,000

18/2/22

Hb-7.4

Tlc-15,800

Plt-66,000

A:-

 SLE Flare .

Ana + ; Anti- ds DNA + ; Coombs -+ 

Fever and polyarthralgia 

Anemia and severe thrombocytopenia.(? Immune destruction) .

P: 

1)Inj.Methyl prednisolone 1g /iv/stat 

2) Tab . Pan 40 mg po/od

3) Tab zofer 4 mg/sos

4) IVF - NS/RL .