This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here after collecting informed patient consent (form downloadable Click Here) by BMJ Elective Student.
A 40 years old female patient came with chief complaints of
Pain in small joints in both upper limbs since 14 months.
C/o rash on left malar area on face since 1 year
C/O hair loss since 1 year
C/O eye discharge since 15 days
History of present illness:
Patient was apparently asymptomatic 1 year back after which she developed joint pains in MCP, PIP, DIP joints of both upper limbs.. not associated with swelling of joints. Two months later patient developed an erythematous rash on left malar and left side of nose associated with hair-loss since 1 year along with photosensitivity
H/O scars and scalings on scalp along with hair-loss since 1 year
The rash was initially erythematous involving malar and left nose which gradually progressed to right malar neck, trunk, upper limbs, abdomen, thigh with in 7 months
Joints pain gradually progressed to wrist joint elbow joint and shoulder joint and small joints of both Lower limbs with in 7 months..
Exacerbation of rash associated with itching and crusting with erosions since 1 month after intake of herbal medication
H/O burning sensation in both eyes along with mucopurulent discharge since 15 days associated with redness on and off. Not associated with blurring of vision or loss of vision.
H/O white plaques on buccal mucosa since 1month
No H/O difficulty in swallowing and chewing
No H/O fever, weight loss easy fatiguability
No H/O abdominal pain, decreased appetite, weight loss
No H/O decreased urine output, burning micturition
No H/o cough, sob, chest pain, palpitations
No H/O seizure, altered behavior
No H/O change in color of limbs on exposure to cold
Past H/O : no H/o similar complaints In the past
Drug H/O : H/o herbal medication since 15 days oral and local application followed by which the rash got exacerbated
Personal history
Diet : mixed
Bladder bowel : regular
Sleep adequate
Appetite normal
Menstrual history no irregularities
Cycle 3/30
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| Figure 1 |
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| Figure 2 |
Investigations after admission:
Rbs - 176mg/Dl
Cue- wnl
Esr- 130MM
Hb 8.1
Tlc 8,900
Pcv -24.5⬇
Mcv-77.9⬇
Mch-25.8⬇
Mchc-33.1
RDW-cv 15.9%
Pc- 2.30 lakhs
T.bil - 1.25mg
D.bil-0.43
Ast-41
Alt-17
Alp-56
Albumin-2.8
Urea-43
Creatine-1
Ca-10.9
Na-137
K-3.5
Cl-98
Skin biopsy report doneyear back:
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| This is fresh lesion |
Cotton wool spots:
CURRENT UPDATE SUMMARY:
2018 rains:
The patient presented this time with fever for weeks along with arthritis and increased pruritus and pain in the skin lesions. In view of the step ladder fever chart and recorded episodes of hypotension post admission, sepsis was suspected although an inflammatory lupus flare was also high on the cards. She was treated with both ceftriaxone and steroids and her symptoms subsided in 2 days. Ceftriaxone was stopped after she remained afebrile for 2 days. There was no leucocytosis in these 2 weeks of her admission.
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