A 29 year old female with SLE

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

This is a case of a 29 year old female working as an application support executive in Mumbai came with the chief complaints of shortness of breath since yesterday night(06/11/21).

HOPI

Patient was apparently alright 5 years ago, back then in 2017 she had complaints of

 -FEVER, continuous, not resolving on medications (pyrexia of unknown origin). 

-MALAR RASH on dorsum of nose and cheeks

-Generalised weakness, malaise

-Ulcers in the oral cavity, which were painful and caused difficulty in food intake.

-Bilateral pain in large joints (knee and ankle), myalgia.

-Diffuse non scarring alopecia, has started loosing hair abnormally since then

-She was screened for ANA which was positive

-Anti- dsDNA antibodies were positive

-She was prescribed prednisolone, MMF, azathioprine. She used them for a while and noticed her symptoms not resolving on medications and stopped using them and also because the cost of medicines were financially burdening.

She was also prescribed sunscreen and was advised not to go out in the sun.

No h/o petechiae, purpura on skin

No h/o psychosis, depressive symptoms

No h/o weight loss

- 1 month ago, 

-She had an episode of severe shortness of breath sudden in onset initially grade 3 progressed to grade 4 (NYHA) and pedal edema and sudden rise in her blood pressure ( hypertensive emergency) for which she was  immediately given medication

She also complains of missed period this month. Cycles regular 3/30 adequate flow, no associated pain abdomen, clots, abnormal discharge.

-Since yesterday night

She complains of sudden onset exacerbation of dyspnea which was on ordinary activity till then,... to even at rest from yesterday night.

3 bouts of vomitings today morning. Projectile, non bilious, non blood stained, non foul smelling, food as a content.

She also had sudden onset involuntary jerky movements of her left limb followed by her whole body 

Her daily routine..???

Past history- 

She had pedal edema and sudden exacerbation of SOB a month ago for which she had dialysis in the month of October- 3 times.

Followed by which she had one packet of blood transfused. Since then she had been on antihypertensives.

No h/o DM, Bronchial asthma, CAD, TB

Personal history- 

Diet - mixed

Appetite- good

Sleep-adequate

Bowel and bladder movements- regular 

No Addictions

Family history-

???

Drug history-

???

Allergy history-

???

General physical examination- 

Patient is concious coherent and cooperative well oriented to time place and person

Vitals on admission

Temperature-

BP

RR

PR

GRBS-

At the time of examination- 6/11/22

Temp - afebrile

BP- 

PR

RR

Pallor+ 

Pedal edema - mild

No icterus clubbing cyanosis lymphadenopathy .

Non scarring alopecia seen

Hyperpigmented discoid rash on cheeks and before ears.

Nails- flat

Excoriations noted on right and left lower limbs.

O/E of oral cavity-

Hyperpigmented patches on oral mucosa noted.