A 20 YEAR OLD FEMALE c/o neck pain since 3 days c/o headache since 1 day, c/o vomiting since 1 day.

A 20 YEAR OLD FEMALE C/o neck pain since 3 days
C/o headache since 1 day.
C/o vomiting since 1 day.
HOPI: 

Patient was apparently alright 3 days ago and then she had a B/L pitting type of pedal edema extending till knee, which was relieved on taking medication, later on she developed fever and hyper pigmented macules on the face, fever was high grade. Later she developed pitting type of pedal edema, Dry cough, abdominal distension, decreased appetite, decreased urine output. All her complaints subsided after she was treated. She was normal till 3 days. Then she developed neckpain, non radiating type and headache since 1 day.

Past history:
Not a k/c/o HTN, DM, ASTHMA,TB EPILEPSY, CAD.
K/c/o SLE. She is on medication :
1)TAB.HCQ 200 MG PO/OF
2)TAB.AZATHIOPRIME 50 MG PO/BD
3) TAB.PREDNISOLONE PO/BD
Personal history:
Diet- Mixed

Appetite- Decreased

Bowel and Bladder movements- Decreased

Family history- Not significant.

O/E : patient is c/c/c.
No pallor, No icterus, No cyanosis, No clubbing, No edema, No lymphadenopathy.
Vitals:
Temp-98°F
PR-84BPM
RR-20CPM
BP- 170/110 MMHG.
SYSTEMIC EXAMINATION:
CVS-
RS-
CNS-
P/A-
INVESTIGATIONS:

Hemogram on 1/12/2022.


Serum urea:


Sr. Creatinine

LFT:


Sr. Electrolytes:


ECG:


DIAGNOSIS: SLE(? LUPUS NEPHRITIS)
TREATMENT:
1.TAB.PCM 500 MG PO /TID
2.TAB.WARFARIN 5MG PO/BD
3.TAB.HCQ 200 MG PO/OF
4.TAB.AZATHIOPRIME 50 MG PO/BD
5. TAB.PREDNISOLONE PO/BD
6.INJ.ZOFER 4 MG IV /BD
7. SYP.SUCRALFATE 15 ML PO/ BD
8.GRBS MONITOR 2ND HOURLY
9. MONITOR VITALS. 

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