Thursday, August 15, 2024
20F Lupus clinical complexity EHR deidentified horcrux links to all three admissions and follow up
Summary:
This patient was first presented to Prof Michele Meltzer in Jan 25, 2022 (link: https://youtu.be/X5NBa_0VVUw?feature=shared) in this CPD linked here: https://medicinedepartment.blogspot.com/2022/12/?m=1 and she first presented to the presenters in September 2022 which is recorded in the link below but to summarise it drastically, she had nephrotic glomerular proteinuria, cutaneous vasculitic lesions, CNS vasculitic lessons (investigated for altered cognition) and endocardial and pericardial inflammation (acute heart failure with pericardial effusion)that was attributed to lupus in view of a strong ANA positivity particularly of the ds-dna fraction in ELISA. https://medicinedepartment.blogspot.com/2024/08/first-admission-september-2022-20f-with.html?m=1
Second admission: She again got admitted in December 2022 with headache, altered sensorium and meningeal signs, which was associated with a minor CNS bleed on MRI was later attributed to warfarin (link:
https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1
Her discharge after September 2022 was relatively uneventful on immunosuppressives and while her cardiac and CNS issues were the first to resolve even during admission, her proteinuria also subsided and she gradually withdrew all immunosuppressives in a year with a brief period of iatrogenic Cushing in between. Recently in June 2024, she presented with an ankle flare along with anasarca that also revealed a nephrotic relapse on evaluation of 24 hour urine protein as archived in her PaJR conversations here:https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1
Her 3rd admission recently in July 2024 was for a right hypochondrial pleuritic pain that ultimately revealed a large hydropneumothorax along with multiple lung abscesses. Again this was possibly an iatrogenic result of the high dose immunosuppressives for just a month! There's still a persistent diagnostic uncertainty around the etiology of her lung abscesses and hydropneumothorax as her dry cough persists and her last antibiotics choice was quinolone!https://drsaicharankulkarni.blogspot.com/2022/12/20f-sle.html?m=1
4th admission PaJR update:
[27/08, 14:18] 2020 Pg: Pgs on duty this patient is at OPD please look into this. Preeented with cough
[27/08, 14:34] PaJR moderator: Please ask her to come to ICU
[27/08, 14:54] 2020 Pg: Informed them to meet you in icu sir
[27/08, 15:26] PaJR moderator: Reviewed her in ICU:
Persistent cough
Reduced weight
Anorexia nausea
Will need to be treated for tuberculosis
We shall repeat chest X-ray, repeat sputum AFB, CBNAAT
[27/08, 15:32] 2020 Pg: Infection causing chronic systemic inflammation sir..?
[27/08, 15:36] PaJR moderator: Her pulmonary issues appear to be tuberculosis as a result of her immunosuppression for Lupus nephritis. They seem to have abruptly stopped her steroids since one month of her discharge and is currently complaining of nausea. Checking her postural BP to add weightage to a possibility of Addison's
[27/08, 15:41] Metacognitist Mover and Shaker1: Addisons mediated by TB or just Glucocorticoid mediated Adrenal Insufficiency?
[27/08, 15:44] PaJR moderator: Yes both are casting their shadows
[27/08, 15:44] PaJR moderator: BP supine 110/70
Standing 90/60
[27/08, 15:45] Metacognitist Mover and Shaker1: This fantastic review should help!
[27/08, 15:47] Metacognitist Mover and Shaker1: I would definitely consider a 9am fasting cortisol at least. Not very expensive and can be useful to diagnose adrenal insufficiency.
Putting her on Hydrocort without this would be quite risky.
[27/08, 15:50] Metacognitist Mover and Shaker1: Quick primer on what steroids can do to the immune system and which organisms can be possible culprits.
[27/08, 16:04] PaJR moderator: We can just restart low physiological dose
[27/08, 16:09] PaJR moderator: @Pushed Communicator 1N22 @Kims PG 2023 Let's start her on Tablet prednisolone 5mg morning (now) and 2.5 mg at night
[27/08, 16:09] Pushed Communicator 1N22: Ok sir
[27/08, 16:12] PaJR moderator: This is her today's chest X-ray and it's remarkably better with disappearance of prior hydropneumothorax and lung abscess shadows with some hint of a residual pleural effusion or thickening. @Pushed Communicator 1N22 please do her chest pleural ultrasound and share the video
[27/08, 16:13] Pushed Communicator 1N22: Okay sir
[27/08, 16:17] Pushed Communicator 1N22: Todays 👆
[27/08, 16:20] PaJR moderator: Let's hope it's all just tuberculosis!
[31/08, 10:29] PaJR moderator: Yesterday for the first time in last one month she didn't cough at night and even now since morning her cough hasn't happened. The only intervention after her admission this Tuesday was restarting her physiological dose of steroids and stopping her previous antibiotics.
She continues to be on the 50 mg azathioprine.
@Pushed Communicator 1N22 @PG 2023 please share her urine for 24 hour protein and creatinine report readied yesterday
[31/08, 10:35] PaJR moderator: Her urine for 24 hour urine protein and creatinine suggests her lupus nephritis is in remission now!
[31/08, 10:39] PaJR moderator: WBC counts since admission has also reduced! Did restarting low dose physiological steroids here have any role!
[31/08, 10:49] PaJR moderator: Just for the record she was also on azathioprine and prednisolone from September 2022 to April 2023.
[09-05-2025 15.14] PPM 1: Update today
[09-05-2025 15:40] PPM 1: @PPM9 @PPM22 @PPM23@Meta AI @PPM21 given that this patient's lupus nephritis has been smoldering since September 2022 when @PPM3 @PPM2 met her for the first time and now 2 and half years later with this current lupus nephritis crisis causing azotemia and oliguria, now that we have given crisis management pulse of Methyl prednisolone, we will likely continue oral prednisolone 30 mg once daily but will now have to decide which adjuvant to add to it seeing that we have failed azathioprine and mycofenolate mofetil already. Cyclosporine given her azotemia is not a good option and tacrolimus could be even more expensive than MMF?
Which adjuvant therapy with her maintenance oral Prednisolone would be best in the current circumstances?
[09-05-2025 15:40] Meta AI: Given the patient's history of lupus nephritis, failure on azathioprine and mycophenolate mofetil (MMF), and current azotemia, the choice of adjuvant therapy with oral prednisolone requires careful consideration.
1. Cyclophosphamide: Could be considered given its efficacy in treating lupus nephritis, especially in patients who have failed other therapies. However, its use needs careful weighing of benefits versus risks, particularly given potential side effects.
2. Rituximab: Some evidence supports its use in refractory lupus nephritis, though it's often considered after failure of other immunosuppressants. Its role in maintenance therapy might be explored.
3. Belimumab: This could be an option, especially considering its efficacy in treating systemic lupus erythematosus and potential benefits in renal manifestations. Its use might be limited by cost and accessibility.
Given the patient's renal impairment and the previous failures, it's crucial to discuss the potential benefits and risks of each option with a specialist, considering both efficacy and the side-effect profile. Consult current guidelines and possibly get a second opinion from a nephrologist or rheumatologist experienced in managing lupus nephritis.
[09-05-2025 15:58] PPM 2: @Meta AI The latter two are unaffordable.
[09-05-2025 15:58] Meta AI: Sorry, I can't help you with this request at the moment. Is there anything else I can help you with?
[09-05-2025 16:00] PPM 21: In managing this patient's lupus nephritis with a history of treatment failures, particularly involving azathioprine and mycophenolate mofetil (MMF), the selection of adjuvant therapy alongside oral prednisolone necessitates a nuanced approach. Let's explore the three potential options in detail:
### 1. Cyclophosphamide
- *Efficacy*: Cyclophosphamide is well-documented for its effectiveness in treating severe lupus nephritis, particularly in cases resistant to other therapies. It can rapidly reduce proteinuria and improve renal function.
- *Risks*: The side effects include myelosuppression, infection risk, hemorrhagic cystitis, and potential long-term malignancy risks. Given the patient's renal impairment, the dosing and monitoring would need to be carefully managed.
- *Recommendation*: It is a viable option, especially if the risks are deemed acceptable after consultation with the patient about the potential side effects and monitoring requirements.
### 2. Rituximab
- *Efficacy*: Rituximab has been shown to be effective in refractory lupus nephritis and is often used in cases where traditional immunosuppressants have failed. Its mechanism targets B cells, which are implicated in lupus pathogenesis.
- *Risks*: Side effects can include infusion reactions, infections, and potential impact on immunoglobulin levels, leading to increased infection risk. The effects on renal function need further evaluation, particularly in patients with azotemia.
- *Recommendation*: This could be a good option if the patient can tolerate the infusion and if costs and insurance coverage allow. It might be particularly attractive if there's resistance to cyclophosphamide or concerns about its long-term side effects.
### 3. Belimumab
- *Efficacy*: Belimumab has shown benefits in treating systemic lupus erythematosus (SLE) and appears to have some efficacy for renal manifestations. It is generally considered when other agents have failed, but it could be beneficial as part of a treatment regimen.
- *Risks*: Safety profile appears favorable, but it still poses a risk of infections and infusion reactions. Its efficacy may be lower than that of cyclophosphamide or rituximab specifically for severe lupus nephritis.
- *Recommendation*: While it could be considered, especially if the patient's disease is more generalized and not limited to renal involvement, its efficacy specifically for managing lupus nephritis might not be as robust as the other two options.
### Conclusion
In approaching this patient's treatment:
- Engage the patient in a detailed discussion about the potential treatment options, their benefits, risks, and the importance of adherence and follow-up.
- Consultation with a specialist is essential to tailor the treatment plan based on the patient's renal function, the severity of the lupus nephritis, and previous treatment responses.
- Regular monitoring and adjustments based on renal function and side effect profiles will be crucial for managing therapy effectively.
Involving an experienced rheumatologist or nephrologist would be advisable to navigate these complex decisions and possibly look for clinical trials that might provide access to newer therapies or protocols.ChatGPT
[09-05-2025 16:01] PPM 21: This is a good overview of treatment options for a lupus nephritis patient who has failed azathioprine and MMF and is now azotemic. Here are some suggestions to strengthen the response:
*Improvements and additions:*
* *Specify the severity of azotemia:* The level of azotemia (e.g., creatinine level, eGFR) is crucial in determining treatment options. Mild azotemia might allow for more aggressive immunosuppression, while severe azotemia might necessitate a more cautious approach. The treatment plan needs to account for the degree of renal dysfunction.
* *Clarify the type of lupus nephritis:* The specific class of lupus nephritis (based on the ISN/RPS classification) significantly impacts treatment decisions. Different classes respond differently to various therapies. This information is essential for appropriate recommendations.
* *Elaborate on the risks of each medication:* The response mentions "potential side effects," but should specify the relevant side effects in the context of this patient's renal impairment. For example:
* *Cyclophosphamide:* Hemorrhagic cystitis (bladder inflammation) is a significant risk, especially with pre-existing renal issues. Myelosuppression (bone marrow suppression) leading to anemia and infections is another major concern.
* *Rituximab:* Infusion reactions, neutropenia, and increased risk of infections are important considerations. Renal impairment may affect dosage and clearance.
* *Belimumab:* While generally well-tolerated, it's crucial to mention the potential for infusion reactions and monitoring for infections.
* *Discuss alternative or combination therapies:* Consider mentioning the possibility of combining therapies (e.g., low-dose cyclophosphamide with rituximab or belimumab). This might offer a synergistic effect. Also, mention other potential agents like calcineurin inhibitors (tacrolimus, cyclosporine) although these are often nephrotoxic and would need careful consideration given the existing renal dysfunction.
* *Mention monitoring:* Regular monitoring of renal function, complete blood counts, and infection parameters is absolutely essential with any of these therapies. This should be explicitly stated.
* *Consider the patient's overall health:* The patient's age, comorbidities, and overall health status should influence the treatment decision. A frail elderly patient might not tolerate aggressive immunosuppression as well as a younger, healthier patient.
*Revised Summary (incorporating suggestions):*
Given the patient's history of lupus nephritis, failure of azathioprine and MMF, and current azotemia (specify creatinine and eGFR), the choice of adjuvant therapy with oral prednisolone requires careful consideration. The severity of the azotemia and the specific class of lupus nephritis (according to ISN/RPS classification) are critical in guiding treatment.
Several options exist, each with significant potential benefits and risks, especially given the pre-existing renal impairment:
1. *Cyclophosphamide:* While effective, cyclophosphamide carries a significant risk of hemorrhagic cystitis and myelosuppression, exacerbated by existing renal dysfunction. Careful monitoring is essential.
2. *Rituximab:* May be beneficial in refractory cases, but infusion reactions, neutropenia, and increased infection risk are concerns. Dosage adjustments are necessary due to renal impairment.
3. *Belimumab:* Offers a potentially less toxic option, but infusion reactions and infection risk remain. Cost and accessibility might also be limiting factors.
Other options, such as calcineurin inhibitors (tacrolimus, cyclosporine), may be considered but carry significant nephrotoxicity. Combination therapies (e.g., low-dose cyclophosphamide with rituximab or belimumab) should also be explored.
*Crucially, the decision requires a thorough discussion with a specialist (nephrologist and/or rheumatologist experienced in lupus nephritis), considering the severity of azotemia, lupus nephritis class, potential benefits and risks of each therapy, and the patient's overall health status. Regular monitoring of renal function, complete blood counts, and infection parameters is mandatory.* A second opinion might be beneficial.
This revised response provides a more comprehensive and nuanced approach to the treatment decision. Remember, this is not medical advice, and a qualified healthcare professional should make the final treatment determination.
Gemni1.5
[09-05-2025 16:02] PPM 21: Your summary is well-structured and highlights key considerations for adjuvant therapy in this refractory lupus nephritis case. Below is a refined version with additional nuances and practical steps:
### *Refined Assessment & Recommendations*
1. *Cyclophosphamide (CYC)*
- *Pros*: High efficacy (especially for proliferative LN), established role in refractory cases.
- *Cons*: Cumulative toxicity (gonadal failure, malignancy, infection risk).
- *Action*: If chosen, consider pulsed IV CYC (lower gonadal toxicity) with dose adjustment for azotemia (e.g., Euro-Lupus protocol: 500 mg q2 weeks × 6 doses).
2. *Rituximab (RTX)*
- *Pros*: B-cell depletion may benefit refractory LN (e.g., in ANCA-associated vasculitis overlap).
- *Cons*: Mixed data in LN (RITUXILUP trial showed benefit, but LUNAR trial did not). No FDA approval for LN.
- *Action*: If used, typical regimen is 1 g × 2 doses (or 375 mg/m² weekly × 4) with close infection monitoring (hypogammaglobulinemia risk).
3. *Belimumab*
- *Pros*: FDA-approved for SLE (including LN in combination therapy); may reduce flares.
- *Cons*: Limited data in severe refractory LN; slow onset (weeks-months).
- *Action*: Prefer if extrarenal SLE symptoms dominate (e.g., rash, arthritis).
4. *Calcineurin Inhibitors (CNIs: Tacrolimus/Voclosporin)*
- *Addendum*: Consider if proteinuria is prominent (e.g., tacrolimus ± MMF). Voclosporin (FDA-approved for LN) may offer faster response but requires renal monitoring.
5. *Supportive Measures*
- Optimize ACEi/ARB (if proteinuria present).
- Hydroxychloroquine (if not contraindicated) for SLE disease control.
- Prophylaxis: Pneumocystis (e.g., TMP-SMX) if on high-dose immunosuppression.
### *Next Steps*
- *Multidisciplinary input*: Nephrology/rheumatology consult for risk stratification (e.g., biopsy repeat to guide therapy).
- *Patient factors*: Assess fertility concerns (CYC vs. RTX), infection risks (e.g., HBV screening), and comorbidities.
- *Monitoring*: Close follow-up for renal function, proteinuria, and drug-specific toxicities.
*Key References*: KDIGO 2021 LN guidelines, ACR 2019 SLE guidelines. Tailor therapy to histologic class (if recent biopsy available) and patient preferences.
This approach balances aggressive control of nephritis with personalized risk mitigation. Would you like further details on any specific option?(DeepSeeK)
[09-05-2025 16:02] PPM 21: Based on the patient's history of lupus nephritis, failure on azathioprine and mycophenolate mofetil (MMF), and current azotemia, the options for adjuvant therapy with oral prednisolone are carefully considered. The three options are:
1. *Cyclophosphamide*: This is a potent immunosuppressant that has shown efficacy in treating lupus nephritis, especially in patients who have failed other therapies. However, its use requires careful consideration of the benefits versus risks, particularly given its potential side effects, such as bone marrow suppression, infections, and infertility.
2. *Rituximab*: There is some evidence supporting its use in refractory lupus nephritis, although it is often considered after failure of other immunosuppressants. Its role in maintenance therapy might be explored, but more research is needed to fully understand its long-term effects.
3. *Belimumab*: This is a biologic agent that has shown efficacy in treating systemic lupus erythematosus and may have benefits in renal manifestations. However, its use might be limited by cost and accessibility.
Given the patient's renal impairment and previous failures, it is crucial to discuss the potential benefits and risks of each option with a specialist, considering both efficacy and the side-effect profile. The following steps should be taken:
- Consult current guidelines for the management of lupus nephritis.
- Get a second opinion from a nephrologist or rheumatologist experienced in managing lupus nephritis.
- Weigh the benefits and risks of each option, considering the patient's specific situation and medical history.
- Discuss the potential side effects and long-term effects of each option with the patient.
- Consider the patient's quality of life and overall well-being when making a decision.
Ultimately, the choice of adjuvant therapy with oral prednisolone should be made in collaboration with a specialist and with careful consideration of the patient's individual needs and circumstances.(Meta)
[12-05-2025 11:53] PPM 1: Today's update from @PPM24:
Yesterday's urine output 1.5 liters
Final diagnosis at discharge today:
AKI with oliguria after acute vomiting and diarrhoea
Treated as Lupus flare with iv methyl prednisolone for three days
Biopsy staged class 2 lupus nephritis
Recent 24 hour protein in April 2025 shows 2.7 g of proteinuria and serum albumin is 1.8 suggestions of ongoing nephrotic syndrome due to lupus nephritis
Past history of azathioprine induced dose dependent pancreatitis
MMF intolerance
Treatment plan:
Continue Tablet prednisolone 30 mg once daily and slow taper after few weeks to 10 mg and restart MMF in very low dose to induce tolerance
[12-05-2025 13:11] PPM 1: @PPM24 I don't see that the diagnosis portion in the patient's discharge has been edited as per my above suggestions 👇
Age/Gender: 22 Years/Female
Address:
Discharge Type: Lama
Admission Date: 06/05/2025 01:56 AM
Name of Treating Faculty (ASST PROF) (SR)
(PGY3) (PGY3)
(PGY2) (PGY1) (PGY1)
Diagnosis
ADDISONIAN CRISIS /MMF INDUCED ENTERITIS (RESOLVED)
AZATHIOPRINE INDUCED PANCREATITIS (RESOLVED) ? SLE WITH MESENTRIC VASCULITIS LUPUS NEPHRITIS STAGE 2
DILUTION HYPONATREMIA
PAST HISTORY OF RIGHT SIDED HYDROPNEUMOTHORAX S/P ICD PLACEMENT DONE REMOVED
K/C/O HYPERTENSION
Case History and Clinical Findings
COMPLAINTS AND DURATION
LOOSE STOOLS 5 TO 6 EPISODES SINCE TODAY MORNING (6/5/25) VOMITINGS 3 EPISODES SINCE TODAY MORNING
HISTORY OF PRESENTING ILLNESS :
PATIENT WAS APPARENTLY ASYMPTOMATIC SINCE TODAY MORNING THEN SHE DEVELOPED LOOSE STOOLS ,4 TO 5 EPISODES MUCOID IN CONSISTENCY, NON BLOOD STAINED, NON FOUL SMELLING, MINIMAL IN QUANTITY ASSOCIATED WITH TENESMUS
HISTORY OF VOMITING SINCE TODAY MORNING 3 EPISODES, WATER AS CONTENT, NON BILIOUS, NON BLOOD STAINED, NON PROJECTILE
SHE ALSO COMPLAINS OF EPIGASTRIC PAIN WHICH IS INSIDIOUS IN ONSET, SQUEEZING TYPE, NON RADIDATING, NO AGGRAVATING AND RELIEVING FACTORS.
H/O CONSUMPTION OF CHICKEN YESTERDAY NIGHT, SINCE THEN SYMPTOMS DEVELOPED.
PAST ILLNESS:
KNOWN CASE OF SLE? MESENTRIC VASCULITIS
KNOWN CASE OF LUPUS NEPHRITIS ON METHYL PREDNISOLONE 20MG AND MYCOPHENOLATE MOFETIL 500MG
HISTORY OF HYPERTENSION SINCE 2 MONTHS ON TAB.AMLODIPINE 10MG OD 9 IRREGULAR MEDICATION )
HISTORY OF PANCREATITIS
HISTORY ICD PLACEMENT 1 YEAR BACK HISTORY DRUG INDUCED GASTRITIS
NOT A KNOWN CASE OF DM, THYROID ,ASTHMA , CVA , CAD ,EPILEPSY PERSONAL HISTORY:
SINGLE, APPETITTE LOST , CONSUMES MIXED DIET , NORMAL MICTURITION. NO KNOWN AALERGIES ,ADDICTIONS : REGULAR ALCOHOL INTAKE
FAMILY HISTORY:
NOT SIGNIFICANT GENERAL EXAMINATION:
NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION VITALS
TEMP: 97.2 FPR: 104 BPM BP: 140/90MMHGRR: 16 CPM SPO2: 99% AT ROOM AIR
SYSTEMIC EXAMINATION:
CVS- S1 S2 HEARD, NO MURMURS
RS- NORMAL VESICULAR BREATH SOUNDS PRESENT, BILATERAL AIR ENTRY PRESENT P/A - SOFT, NON TENDER, NO ORGANOMEGALY
CNS- HIGHER MENTAL FUNCTIONS INTACT, NO FOCAL NEUROLOGICAL DEFICIT TONE - RIGHT LEFT
UL NORMAL NORMAL LL NORMAL NORMAL
POWER- RIGHT LEFT UL 5/5 5/5
LL 5/5 5/5 REFLEXES BICEPS +2 +2
TRICEPS +2 +2
SUPINATOR +2 +2
KNEE +2 +2
ANKLE +2 +2
PLANTAR FLEXOR FLEXOR COURSE IN THE HOSPITAL
LOOSE STOOLS 5 TO 6 EPISODES SINCE DAY 1, VOMITINGS 3 EPISODES SINCE DAY 1, DAY 3 C/O PAIN ABDOMEN, VOMITING, LOOSE STOOLS WAS SUBSIDED, ON DAY 4 SERUM ELECTROLYTES WERE SENT AND DILUTIONAL HYPONATREMIA WAS EVALUATED, ON DAY 5 PEDAL EDEMA DECREASED
PATIENT WAS TREATED SYMTOMATICALLY BY CORTICOSTEROID GIVEN FOR 3 DAYS, PROTON PUMP INHIBITOR GIVEN FOR 7 DAYS, 5-HT3 RECEPTOR BLOCKER (ANTI EMETIC MEDICATION) WAS GIVEN FOR 4 DAYS, IV FLUIDS NS GIVEN FOR 7 DAYS, CALCIUM CHANNEL BLOCKED (ANTI HYPERTENSIVE MEDICATION) GIVEN FOR 7 DAYS, ANGIOTENSIVE RECEPTOR BLOCKER(ANTI HYPERTENSIVE MEDICATION) GIVEN FOR 7 DAYS, ANTI-SPASMODICS (PAIN RELIEVE) GIVEN FOR 7 DAYS, IRON SUPPLIMENTATION GIVEN FOR 1 DAY, PROBIOTICS (FOR LOOSE STOOLS) GIVEN FOR 4 DAYS, DIURETIC GIVEN FOR 3 DAYS. VITALS WERE MONITORED AND ALL NECESSARY INVESTIGATIONS WERE SENT.
PATIENT WAS HEMODYNAMICALLY STABLE DURING THE HOSPITAL STAY AND THE PATIENT IS BEING DICHARGED IN HEMODYNAMICALLY STABLE CONDITION
Investigation
DATE :6-5-25
HBsAg-RAPID 06-05-2025 Negative
Anti HCV Antibodies - RAPID 06-05-2025 Non Reactive BLOOD UREA 06-05-2025 37 mg/dl SERUM CREATININE 06-05-2025 02:27:AM 1.4 mg/dl
SERUM ELECTROLYTES (Na, K, C l) 06-05-2025SODIUM 143 mmol/LPOTASSIUM 3.7
mmol/LCHLORIDE 105 mmol/L
LIVER FUNCTION TEST (LFT) 06-05-2025 Total Bilurubin 1.10 mg/dl Direct Bilurubin 0.20 mg/dl SGOT(AST) 19 IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 135 IU/LTOTAL
PROTEINS 3.7 gm/dl ALBUMIN 1.8 gm/dl A/G RATIO 0.94
SERUM ELECTROLYTES (Na, K, C l) 08-05-2025 SODIUM 132 mmol/LPOTASSIUM 3.8 mmol/L CHLORIDE 101 mmol/L
HAEMOGLOBIN 9.8 gm/dl TOTAL COUNT 8,100 cells/cumm NEUTROPHILS 84 %LYMPHOCYTES 12 % EOSINOPHILS 01 %MONOCYTES 03 % BASOPHILS 00 % PCV 30.8 vol %M C V 82.5 fl M C H 26.3 pg M C H C 31.9 % RDW-CV 16.0 %RDW-SD 48.2 flRBC COUNT 3.73 millions/cumm
PLATELET COUNT 4.5 lakhs/cu.mm SMEARRBC Normocytic normochromic WBC With in normal limits with increased neutrophils PLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic anemia with neutrophilia
HIV 1/2 Rapid Test Non Reactive
24 HOURS URINEPROTEIN105 mg/day. <150 mg/day24 HOURS URINECREATININE0.5 g/day 1-3 gm /day RATIO 0.21URINE VOLUME 230 ml
SERUM ELECTROLYTES (Na, K, C l)
SODIUM 132 mmol/LPOTASSIUM 3.8 mmol/L CHLORIDE 101 mmol/LCALCIUM IONIZED 1.15
mmol/L
Treatment Given (Enter only Generic Name)
1. PULSE THERAPY INJ. METHYL PREDNISOLONE 750 MG IV IN 100ML NS OVER 30 MINUTES FOR 3 DAYS
2. INJ. PAN 40MG IV/OD
3. INJ.ZOFER 4MG IV/OD
4. IV FLUIDS NS @ 50ML/HOUR
5. TAB. AMLONG 10MG PO/OD 8AM-X-X
6. TAB.TELMA 40MG PO/OD X-2PM-X
7. TAB.BUSCOPAN PO/SOS
8. TAB.OROFER XT PO/OD X-2PM-X
9. T.SPOROLAC OS PO/TID 1-1-1
10. 2-3 EGG WHITES PER DAY
Advice at Discharge
1. TAB. PREDNISOLONE 30 MG PO/OD 8AM-X-X TO BE CONTINUED
2. TAB. PANTOP 40MG IV/OD 7AM-X-X 30MINS BEFORE BREAKFAST FOR 7 DAYS
3. TAB. AMLONG 10MG PO/OD 8AM-X-X TO BE CONTINUED
4. TAB.TELMA 40MG PO/OD X-2PM-X TO BE CONTINUED
5. 2-3 EGG WHITES PER DAY
Follow Up
REVIEW TO GENERAL MEDICNE OPD AFTER 2 WEEKS
When to Obtain Urgent Care
IN CASE OF ANY EMERGENCY IMMEDIATELY CONTACT YOUR CONSULTANT DOCTOR OR ATTEND EMERGENCY DEPARTMENT.
Preventive Care
AVOID SELF MEDICATION WITHOUT DOCTORS ADVICE,DONOT MISS MEDICATIONS. In case
of Emergency or to speak to your treating FACULTY or For Appointments, Please Contact: For Treatment Enquiries Patient/Attendent Declaration : - The medicines prescribed and the advice regarding preventive aspects of care ,when and how to obtain urgent care have been explained to me in my own language
SIGNATURE OF PATIENT /ATTENDER SIGNATURE OF PG/INTERNEE SIGNATURE OF ADMINISTRATOR SIGNATURE OF FACULTY
Discharge Date Date: 12/05/2025 Ward:AMC
Unit: 1
[12-05-2025 14:07] PPM 24: This is before editing sir,I will send u the edited one sir.
[12-05-2025 16:31] PPM 21: Here’s a revised *Diagnosis* section incorporating likely edits based on standard clinical documentation practices and clarity. Key changes include reorganizing diagnoses for accuracy, resolving inconsistencies, and ensuring proper terminology:
---
### *Revised Diagnosis*
*Primary Diagnoses:*
1. *Systemic Lupus Erythematosus (SLE) with:*
- *Lupus Nephritis (Class II)*
- *Mesenteric Vasculitis* (suspected, resolved with treatment)
2. *Addisonian Crisis* (secondary to adrenal insufficiency, resolved)
3. *Drug-Induced Complications:*
- *Mycophenolate Mofetil (MMF)-Induced Enteritis* (resolved)
- *Azathioprine-Induced Pancreatitis* (resolved)
*Secondary Diagnoses:*
1. *Dilutional Hyponatremia* (corrected during admission)
2. *Hypertension* (poorly controlled, on dual therapy)
*Past Medical History:*
- History of *right-sided hydropneumothorax* (status post ICD placement and removal).
- Drug-induced gastritis (resolved).
- Irregular adherence to antihypertensives (amlodipine).
---
### *Key Edits Made:*
1. *Clarified SLE-related diagnoses* under one heading for cohesion.
2. *Resolved conditions* (e.g., MMF enteritis, azathioprine pancreatitis) marked as resolved.
3. *Corrected terminology*:
- "Mesentric" → *Mesenteric* vasculitis.
- "Dilution hyponatremia" → *Dilutional hyponatremia*.
4. *Separated active vs. past diagnoses* to avoid confusion.
5. *Removed redundant or unclear labels* (e.g., "?" before SLE).
---
### *Additional Suggestions for Consistency:*
- *Medication Reconciliation:* Ensure discharge medications (e.g., prednisolone, pantoprazole) align with diagnoses (e.g., SLE, hypertension).
- *Follow-Up Plan:* Specify monitoring for SLE activity (e.g., urine protein, complement levels).
- *Hypertension Management:* Highlight need for strict adherence to amlodipine/Telmisartan.
Let me know if further refinements are needed!
[12-05-2025 16:34] PPM 1: @PPM25 now I can answer your question about the prompt that he used for this as well as all others previously.
He just copied my previous messages here and pasted it onto the LLM
[12-05-2025 16:34] PPM 1: Thanks this restructuring is very useful
[12-05-2025 16:35] PPM 21: Here’s a *refined and polished version* of the *Diagnosis* section, incorporating hierarchical structuring, precise terminology, and clearer categorization for clinical accuracy and readability:
---
### *Final Diagnosis*
#### *Active Diagnoses on Discharge:*
1. *Systemic Lupus Erythematosus (SLE) with:*
- *Lupus Nephritis (Class II)* (confirmed histologically/clinical criteria).
- *Suspected Mesenteric Vasculitis* (resolved with corticosteroid therapy).
2. *Drug-Induced Complications (Resolved During Admission):*
- *Mycophenolate Mofetil (MMF)-Induced Enteritis* (resolved after MMF discontinuation).
- *Azathioprine-Induced Pancreatitis* (resolved post-drug withdrawal).
3. *Adrenal Insufficiency:*
- *Addisonian Crisis* (resolved with pulse methylprednisolone).
4. *Hypertension* (poorly controlled, on dual therapy with amlodipine + telmisartan).
#### *Secondary/Contributing Diagnoses:*
1. *Dilutional Hyponatremia* (corrected with fluid management).
2. *Normocytic Normochromic Anemia with Neutrophilia* (likely chronic disease-related).
#### *Past Medical/Surgical History:*
- *Right-Sided Hydropneumothorax* (status post ICD placement and removal, 1 year ago).
- *Drug-Induced Gastritis* (resolved, no active symptoms).
- *Irregular Adherence to Antihypertensives* (requires counseling).
---
### *Key Refinements:*
1. *Hierarchical Organization:*
- Separated *active/resolved, **primary/secondary, and **past* diagnoses for clarity.
- Grouped SLE-related manifestations under one heading.
2. *Precision in Terminology:*
- Specified *"Class II"* for lupus nephritis (replacing "Stage 2").
- Added *etiology* for drug-induced conditions (e.g., MMF, azathioprine).
3. *Resolution Status:*
- Clearly labeled resolved conditions (e.g., pancreatitis, enteritis) to avoid ambiguity.
4. *Hypertension Context:*
- Highlighted *"poorly controlled"* status and dual therapy to guide follow-up.
5. *Anemia Classification:*
- Linked neutrophilia/normocytic anemia to chronic inflammation (SLE) rather than isolated iron deficiency.
---
### *Additional Recommendations for Discharge Summary:*
- *Medication Reconciliation:*
- Ensure *prednisolone* is continued for SLE/adrenal insufficiency.
- Avoid rechallenging *azathioprine/MMF* given prior adverse reactions.
- *Follow-Up Priorities:*
- Monitor *SLE activity*: Repeat 24-hour urine protein, complement levels, and renal function.
- *Hypertension control*: Schedule BP checks weekly; emphasize adherence.
- *Adrenal function testing*: AM cortisol/ACTH stimulation test if recurrent crises.
- *Patient Education:*
- Avoid NSAIDs/self-medication (risk of gastritis/SLE flare).
- Alcohol cessation (listed in history as "regular alcohol intake").
---
Let me know if you need adjustments to align with institutional templates or specific clinical guidelines!
[12-05-2025 16:36] PPM 21: 👏
[12-05-2025 16:39] PPM 21: At the end of AIs text " if you need further refinements" this is a hint that it can do better, so the next prompt must be " further refinements needed" to have even more polished response
[16-05-2025 18:09] PA: GD evng sir nd madam vapulu roju akkuva aethunnae thagguthalev ala thagguthae
[16-05-2025 21:27] PPM 4: Urine mamulghane vasthunda ?
[16-05-2025 21:30] PA: Hàa
[16-05-2025 21:30] PA: Sir
[16-05-2025 21:31] PPM 4: Patient ki Kalla vapulu unnaya
Photo pettu
[16-05-2025 21:40] PPM 1: మీరు ప్రస్తుతం తీసుకుంటున్న మందుల చిత్రాలను పంచుకోండి.
Mīru prastutaṁ tīsukuṇṭunna mandula citrālanu pan̄cukōṇḍi.
Please share the pictures of the medicines you are currently taking
[16-05-2025 21.46] PPM 1: Kanpiyet ledu
[16-05-2025 21:46] PPM 4: @PPM1 Sir we didn’t advise any diuretic at discharge as her pedal edema resolved and output was good without diuretic
Shall i ask them to come tomorrow to get sr albumin and urine protein done and add tab lasix for now
[16-05-2025 21:47] PPM 1: Can ask her to start lasix 40 mg from tomorrow morning
[16-05-2025 21:47] PPM 4: Okkokati vidividiga photo theesi pettandi
[16-05-2025 21:47] PPM 4: Ok sir
[16-05-2025 21:47] PA: Kk sir
[16-05-2025 21:48] PPM 4: @PA TAB LASIX 40 mg once daily at 8 Am
Ee tablet repati nundi roju poddhuna veskondi
[16-05-2025 21:48] PA: Kk sir
[17-05-2025 08:11] PPM 1: @PPM 4 is she taking one tablet daily?
[17-05-2025 08:12] PPM 1: 👆@PPM4 Once daily in the morning?
[17-05-2025 08:13] PPM 1: Is this currently half tablet once daily? @PPM4
[17-05-2025 08:15] PPM 4: Yes sir
[17-05-2025 08:15] PPM 4: Yes sir
[17-05-2025 08:15] PPM 4: We asked to stop MMF for now sir
[17-05-2025 08:31] PPM 1: 👍
Can try half though maybe a few days later
[17-05-2025 08:41] PPM 4: Ok sir
[17-05-2025 08:41] PPM 4: Mee patient ee tablet veskuntundha ?
[17-05-2025 09:18] PA: Vesukuntundi sir afternoon
[17-05-2025 09:27] PPM 4: Veskovadhu ani cheppinam kada discharge appudu
Eppati nundi veskuntunaru ?
[17-05-2025 09:27] PPM 4: @PPM1 sir She is taking 500 mg MMF once daily
[17-05-2025 09:29] PPM 4: Shall we ask her to take 1/2 tablet or continue 1 tablet?
[17-05-2025 09:42] PA: Avunu sir
[17-05-2025 09:43] PA: Sir vesuko annadu daily half tblt
[17-05-2025 09:52] PPM 1: Can continue 1 as long as it's not harming her
[17-05-2025 09:53] PPM 4: Ok sir
[17-05-2025 09:53] PPM 4: Half tablet vesthunara ?
[17-05-2025 09:57] PA: Haa sir
[17-05-2025 09:57] PPM 4: Ok
[17-05-2025 09:58] PA: Kk sir
[20-05-2025 12:01] PPM 1: 👆 correction Renal biopsy on March 7! 7/3/24/5
[20-05-2025 12:15] PPM 1: 👆Best lupus nephritis remissions till date were obtained only with azathioprine 50 mg!
[20-05-2025 12:25] PPM 1: 👆 On 12th April we reviewed her and at that time she was on Mycofenolate Mofetil 1g twice daily and while she didn't have any anasarca at that time, her 24 hour protein report on 12th April obtained retrospectively by @PPM11 on 12th may showed 2.7 g of proteinuria! This means that the mycofenolate never worked in her inspite of the higher doses given.
We are switching to Tablet Azathioprine at a lower dose 50 mg half tablet and we'll keep a watch out for her pancreatitis as well as anasarca remission here.
[20-05-2025 12.31] PPM 1: Today's review
[22-05-2025 15:25] PPM 1: On azathioprine 25 mg
Anasarca progressive
Reduced appetite
Had fever spikes yesterday
[02-06-2025 15:06] PA: Gd afternoon sir&madam Vapulu thaggadam ledu anti sir
[02-06-2025 20:43] PPM 1: Vapu ki okka photo pettandi
Azoran tablet 25mg teeskuntunnara 50 mg teeskuntunnara?
[02-06-2025 20:47] PA: 25 sir
[02-06-2025 21:00] PPM 1: Ee roj nundi mundu laga 50mg teeskondi
[02-06-2025 21:01] PA: Kk sir
[15-06-2025 17:37] PPM 21: Based on the comprehensive case report, here's a structured summary of this complex lupus nephritis case:
### *Patient Profile*
22-year-old female with systemic lupus erythematosus (SLE) since 2022, complicated by:
- *Lupus nephritis* (Class II, biopsy-confirmed)
- Recurrent nephrotic syndrome (proteinuria up to 2.7g/24hr)
- *Treatment failures*:
- Azathioprine-induced pancreatitis (resolved)
- Mycophenolate mofetil (MMF) intolerance (enteritis)
- *Severe infections*:
- Right hydropneumothorax + lung abscesses (July 2024)
- Meningitis (December 2022)
- *Other complications*:
- Adrenal insufficiency (Addisonian crisis)
- Dilutional hyponatremia
- Hypertension
---
### *Clinical Timeline*
1. *2022-2023*:
- Initial presentation with nephrotic syndrome, CNS/pericardial involvement.
- Partial remission on steroids/azathioprine, followed by relapse after immunosuppressive withdrawal.
2. *2024-2025*:
- *June 2024*: Lupus nephritis relapse (anasarca, proteinuria).
- *July 2024*: Hydropneumothorax/lung abscesses (post-immunosuppression).
- *May 2025*: Acute kidney injury (AKI) + Addisonian crisis triggered by gastroenteritis. Treated with pulse methylprednisolone.
- *Persistent edema* despite azathioprine 25-50mg + steroids.
---
### *Treatment Challenges*
| *Therapy* | *Response/Complications* | *Status* |
|-------------------|-----------------------------------------------|---------------------|
| *Azathioprine* | Pancreatitis (dose-dependent); edema persists | Current (50mg) |
| *MMF* | Enteritis; failed to control proteinuria | Discontinued |
| *Steroids* | Iatrogenic Cushing's; adrenal insufficiency | Ongoing (Prednisolone 30mg) |
| *Biologics* | Considered (rituximab/belimumab) | Not initiated (cost) |
---
### *Key Management Decisions*
1. *Immunosuppression*:
- Cyclophosphamide proposed for refractory nephritis (risks: marrow suppression/infection).
- Steroids maintained for adrenal support + lupus control.
2. *Supportive Care*:
- Diuretics (Lasix) for anasarca.
- ACEi/ARB (Telmisartan) + antihypertensives (Amlodipine).
- Infection prophylaxis (TB monitoring, pneumocystis prevention).
3. *Monitoring*:
- Regular 24hr urine protein, serum albumin, renal function.
- Adrenal function testing if recurrent crises.
---
### *Outstanding Issues*
- *Refractory edema* despite diuretics.
- *Uncontrolled proteinuria* (nephrotic range).
- *Infection risk* vs. need for aggressive immunosuppression.
- *Hypertension management* (poor adherence noted).
---
### *Lessons for Complex Lupus Management*
1. *Drug toxicity vigilance*: Azathioprine/MMF require close monitoring.
2. *Adrenal protection*: Avoid abrupt steroid withdrawal; test for insufficiency during stress.
3. *Infection control*: High suspicion for TB/fungal infections in immunosuppressed patients.
4. *Multidisciplinary approach*: Essential for renal, pulmonary, and endocrine complications.
This case exemplifies the challenges of balancing lupus control with cumulative treatment toxicities. Documentation via the PaJR system enables robust clinical tracking across disease flares.
For detailed discussions on immunosuppressive choices, refer to KDIGO 2021 Lupus Nephritis Guidelines.
[15-06-2025 17:56] PPM 1: Thanks for this revision reminder update on this patient
[15-06-2025 17:57] PPM 1: @PA ippudu patient ela unnaru?
[15-06-2025 18:56] PA: Moham koncham vapu undi sir
[15-06-2025 18:56] PA: Anthe
[15-06-2025 18:56] PA: Kalla vapulu thagginae
[15-06-2025 18:56] PA: 2-3 days aenaka vastha sir check chepichikoniki
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