THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[02-09-2025 16.10] PPM 1: @PPM3@PPM4 can you share her history?
[18-09-2025 12.36] PPM 1: Reviewed in OPD just now:
Was earlier sent home by @PPM5 with Rx for SLE on HCQ and methyl pred.
Now after reviewing we managed to convince her it's predominantly RA with severe erosions and started her on Methotrexate as a dmard for RA
[18-09-2025 14:32] PPM 1: @PPM5 please share her x-ray hands
[18-09-2025 14:33] PPM 1: @CR here's last admission EMR summary where the diagnosis of RA was absent.
Age/Gender: 51 Years/Female
Address:
Discharge Type: Relieved
Admission Date: 28/08/2025 09:11 PM
Diagnosis
? SLE? SCLERODERMA WITH CUSHING SYNDROME, DENOVO HYPERTENSION
CHRONIC NON-HEALING ULCER WITH CELLULITUIS OF LEFT LOWER LIMB
SEPTIC + HYPOVOLEMIC SHOCK SECONDARY TO ACUTE GASTROENTERITIS [ RESOLVED]
Case History and Clinical Findings
COMPLAINTS OF FEVERHIGH GRADE ALONG WITH CHILLS AND RIGOR, SINCE YESTERDAY
NIGHT, BURNING MICTURITION SINCE 2 DAYS.
H/O VOMITINGS 3 EPISODES WITH FOOD AS CONTENT, NON-BILIOUS, WATERY LOSE
STOOLS-3 EPISODES, NON-FOUL SMELLING AND NON-BLOOD TINGED. H/O OF OUTSIDE
FOOD CONSUMPTION PRESENT YESTERDAY.,H/O STEROID ABUSE SINCE 5 MONTHS
H/O JOINT PAINS [SMALL AND LARGE] SINCE 10 YRS, DRY SCALY SKIN WITH ITCHING SINCE 1 YEAR, HARD THICK SKIN SINCE 5 MONTHS
PAST HISTORY: K/C/O UNKNOWN RHEUMATOLOGICAL DISEASE SINCE 10 YEARS ON
UNKNOWN IRREGULAR MEDICATION, N/K/C/O T2DM, HTN, ASTHMA, THYROID DISORDERS,
CVA, CAD OR TB., CHRONIC ULCER OVER LEFT SHIN SINCE 2 MONTHS.
PERSONAL HISTORY: HOUSEWIFE, DECREASED, DECREASED APPETITE, SLEEP
INADEQUATE, REGULAR BOWEL &BLADDER HABITS, ALLERGIC TO MEAT, LADYS FINGER, ADDICTIONS - CHROINIC TOBACCO CHEWER SINCE 10 YEARS 250GRAMS /DAY
GENERAL EXAMINATION: PATIENT IS C/C/C.PALLOR PRESENT, NO ICTERUS, CYANOSIS,
CLUBBING, LYMPHADENOPATHY OR PEDAL EDEMA. VITALS: TEMP-98.2F, SBP 60MMHG,
PR-86BPM, RR-19 CPM, SPO2-95% AT RA, GRBS-76MG/DL. SYSTEMIC EXAMINATION: CVS,
CNS, RS, P/A- NORMAL
KIMS HOSPITALS
DERMATOLOGY REFERRAL: I/V/O DRY SCALY SKIN WITH ITCHING, NAIL CHANGES AND
HARD THICK SKIN ON PALMS AND WAS DIAGNOSED AS? SYSTEMIC LUPUS
ERYTHEMATOSIS? CONNECTIVE TISSUE DISORDER WITH ONUCHOMYCOSIS, ANA
PROFILE TEST WAS ADVICED.
GENERAL SURGERY REFERRAL: I/V/O NON-HEALING ULCER OVER LEFT TIBIA OVER THE SHIN AND WAS DIAGNOSED AS CHRONIC NON-HEALING ULCER WITH CELLULITIS OVER LEFT LOWER LIMB AND APPROPRIATE TESTS AND MEDICATIONS WERE ADVISED.
Investigation
ON 28/8/2025 - HEMOGRAM: HB-9.0G/DL, TLC-30,000, RBC-3.75 MILLION/MM3, PLT-2.56
LAKH/MM3, RBS:205MG/DL, HBA1C: 6.4% , RFT: BLOOD UREA-37, SR.CREAT-2.5, NA-132, K-3.4, CL-92 LFT: T.BILIRUBIN-0.88, D.BILIRUBIN-0.19, SGPT-10, SGOT-16, ALP-103, ALBUMIN-
2.8, A/G RATIO-1.66. PERIPHERAL SMEAR: MICROCYTIC HYPOCHROMIC ANEMIA WITH
NEUTROPHILIC LEUKOCYTOSIS, ESR - 75 MM/HR,
ON 2/9/2025 HEMOGRAM: HB-9.3 G/DL, TLC-12300, RBC-3.96 MILLION/MM3, PLT-3.27
LAKH/MM3 UPCR: 0.20. HEMOGRAM: HB-8G/DL, TLC-21500, RBC-3.3 MILLION/MM3, PLT-2.0 LAKH/MM3. RFT: BLOOD UREA-20, SR.CREAT-1.0, U.A - 2.5, CA - 10.2, NA-138, K-5.1, CL-100, SPOT - URINE CREAT-29, PROTEIN - 6.0, UPCR - 0.20, 24 HOUR URINE PROTEIN - 120
MG/DL, CREATININE - 0.80, RA FACTOR - NEGATIVE, CRP - POSITIVE 9.6 MG/DL, LDH - 249
.60 IU/L, LACTATE - 18.8 MG/DL, RETICULOCYTE COUNT: 1.0%, T3 -1.4 T4 -10.6 TSH -1.36
USG ABDOMEN - B/L GRADE 1 RPD CHANGES .2D ECHO SCREENING- CONCENTRIC LVH
Treatment Given (Enter only Generic Name)
IVF 3 PINT NS F/B NS, RL @75ML/HR WITH 1 AMP OPTINEURON; INJ. CIPROFLOXACIN 500MG
IV/BD FOR 5 DAYS; INJ. METROGYL 500MG IV/TID FOR 5 DAYS; INJ. PAN 40MG IV/OD; INJ.
ZOFER 4MG IV/TID; TAB. METHLYPREDNISOLONE 40MG FOR 2 DAYS; TAB. CHYMEROL
FORTE PO/TID; SYP.ALKASTONE B6 15ML PO/TID; OINTMENT VENUSIA MAX MOISTURISING
LOTION L/A/BD, MGSO4 DRESSING; TAB HCQ 200MG PO BD; TAB TELMA 40MG PO OD
Advice at Discharge
TAB. METHLYPREDNISOLONE 40 MG PO/OD FOR 5 DAYS F/B TAB PREDNISOLONE 30 MG PO OD FOR 1 WEEK [ PLAN TO TAPER IN FURTHER FOLLOW UPS]
TAB HCQ 200MG PO BD TO CONTINUE
TAB. CHYMEROL FORTE PO/TID FOR 3 DAYS
TAB CIPROFLOXACIN 500MG PO BD FOR 2 DAYS
TAB METROGYL 400MG PO TID FOR 2 DAYS
TAB REJUNEX CD3 PO OD FOR 15 DAYS
OINTMENT VENUSIA MAX MOISTURISING LOTION L/A/BD FOR TWO WEEKS
STRICT TOBACCO ABSTINENCE, PLENTY OF ORAL FLUIDS
Page-3
KIMS HOSPITALS
REGULAR DRESSINGS FOR LEFT LOWER LIMB
Follow Up
REVIEW TO GENERAL MEDICINE OPD AFTER 1 WEEKS/SOS, TO SURGERY OPD AFTER 3
DAYS
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/Attendant 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:2/9/2025 Ward: AMC Unit: IV
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