24 year old female with chills and fever , known case of sle
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Case presentation:
A24 year old female presented with fever with chills since 4- 5 days associated with sorethroat , difficulty in swallowing since 10 days , burning micturition since 3-4 days
She was apparently asymptomatic 2 years back,
On 5th December 2018 she developed multiple joint pains, fever with chills and rigor, she went to physician and took some medications which relieved her symptoms. After 3weeks she had similar complaints and took same medication. From then the she had mild joint pains but can do her daily activities.
In june 2019 her parents planned her marriage but she developed Rash behind the right ear and over the face also had joint pains, low grade fever so she underwent antibody tests and found out ANA positive on 26/6/2019. ( ANA: 4.04 ; Anti dsDNA 2.33) She’s on medication for SLE for 1month
On 24/7/19 she had generalized body pains and articualar pain for which she took 1 month medication and discontinued as she had hair fall due to that medications.
until 22/5/2020 she did not use any medications. But had mild joint pains. On 22/5/2020 she developed sever joint pains, rash behind her ear and starting taking medicines regularly after taking her consultant opinion. She went for a regualr checkup every month.
But since 10 days she had difficulty in swallowing and fever with chills and rigor.
Dysphagia to both liquids and solids
No h/o cold
No h/o cough , GE symptoms
Past h/o
H/o SLE diagnosed 1 1/2 yr back in Dec 18th in view of multiple joint pains
She used treatment for 1 month on June 19th , she started on
T.METHYL PREDININSOLONE 4 MG OD
TAB MYCOPHENOLIC 360 MG OD
T HCQ 200 MG OD
h/o UTI in june
N/k/c/o of DM , HTN, CAD, TB
Personal History :-
Mixed diet
Appetite decreased
Sleep adequate
Bowel movements regular
O/E
pt is conscious, coherent, cooperative
Pallor present
No cyanosis ,icterus , clubbing , lymphadenopathy
Erythematous papules behind both ears and few on upper chest since 15 days
Oral examination
Multiple ulcers present on the buccal mucosa right and left buccal mucosa ,oropharynx
ulcers present in anterior and posterior pillar of tonsil and soft palate
Vitals
Temp - 103.4
Pr- 96bpm
Bp- 90/60mmhg
Spo2 - 98%
Grbs 121 mg %
CVS - No scars
S1 & S2 heard
P/A - soft & nontender
CNS - Higher mental functions normal
No sensory and motor defects
All cranial nerves intact
No signs of cerebellum dysfunction.:
INVESTIGATIONS :-
Hemogram:-
LFT
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