20 yr girl with b/l pedal edema

 This is an E log book to discuss our patient's de-identified health data shared after taking his guardian's signed informed consent. Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs. This e-log book also reflects my patient centered online learning portfolio and your valuable comments in comment box are most welcomed 

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

A pavan kumar 

1701006011

Presentation 

https://youtu.be/GFASTNR78Ng

20 year female came to casualty with chief complaints of 

-Hyperpigmented macules since 15 days

-b/l pedal edema since 15 days 

Fever 15 days back

-abdominal distension since 8 days 

-cough(dry) since 7 days 

-Sore throat since 7 days 

-decreased appetite since 7 days 

-decreased urine output since 3 days 

-constipation since 3 days 

-SOB since 5 days

HOPI 

20 year old female came with c/o of b/l pitting type pedal edema extending till knees since 15 days to which she got medical health checkup and prescribed some medication (unknown) then her pedal edema got resolved along with fever she developed Hyperpigmented macules on face later they stopped medications after 2 days she again had a complaints of b/l pedal edema  and fever abdominal distension associated with dry cough and decreased appetite she also has a complaints of DECREASED urine output and constipation since 3 days passing stools once in 3 to 4 days  

N/k/c/o HTN DM THYROID DISORDER CAD EPILEPSY TB

Personal history: 

Mixed diet 

Appetite lost 

Non veg diet 

Bowel and bladder movements are decreased 

Family history :

No significant family history 

O/E :

Pt was c/c/c 

On admission vitals are 

Bp 110/70 

PR 79 

RR 19 

Temp 98.8 

CVS- apex beat replaced laterally palpable thrills and s1 s2 heard mild s3

RS - BAE decreased rt infra scapular crepts present

P/a umblicus is everted

CNS 

MMSE 

         https://youtu.be/XUOFp5odTnw

https://youtube.com/shorts/9YYfuCgbNl8?feature=share

https://youtube.com/shorts/ZN8AZcvPjYs?feature=share

https://youtu.be/8-tpKi6TZ_A

Investigations:

30/9/22 

28/09/22

Pleural tap

ANA PROFILE

28/9/22

ICU BED NO. 2

S 

B/l pedal edema SOB 

Fever spikes 

O

Pt c/c/c 

Bp - 120/70 

PR - 142 

RR- 29

Temp-99.5

Spo2 - 94 at room air 

A

Post streptococcal glomerulonephritis..??

IGA nephropathy..??

Infective endocarditis..??

P

1)INJ Augmentin 1.2gm iv BD

2)INJ lasix 40mg iv BD

3) NEB Duolin, Budocort 6th hourly

4) INJ neomol 1gm/iv/sos

5) TAB Azithromycin 500mg po bd 

6) Betadine gargles tid

29/9/22

ICU BED NO. 2

S 

B/l pedal edema SOB 

Fever spikes 

O

Pt c/c/c 

Bp - 120/70 

PR - 142 

RR- 29

Temp-99.5

Spo2 - 94 at room air 

A

Post streptococcal glomerulonephritis..??

IGA nephropathy..??

Infective endocarditis..??

P

1)INJ Augmentin 1.2gm iv BD

2)INJ lasix 40mg iv BD

3) NEB Duolin, Budocort 6th hourly

4) INJ neomol 1gm/iv/sos

5) TAB Azithromycin 500mg po bd 

6) Betadine gargles tid 

30/9/22

ICU BED NO. 2

S 

Fever spikes +

Stools not passed 

O

Pt c/c/c 

Bp - 1110/70 

PR - 128

RR- 29

Temp-100.6

Spo2 - 94 at room air 

A

Post streptococcal glomerulonephritis..??

IGA nephropathy..??

Infective endocarditis..??

Polyserositis 2' to SLE

P

1)INJ Augmentin 1.2gm iv BD

2)INJ lasix 40mg iv BD

3) NEB Duolin, Budocort 6th hourly

4) INJ neomol 1gm/iv/sos

5) tab prednisolone 50mg po bd 

6) Betadine gargles tid

7) inj pan 40 mg iv bd 

1/10/22

ICU BED NO. 2

S 

B/l pedal edema subsided

COUGH +

O

Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

infective endocarditis

Drug induced 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLY

2/10/22

ICU BED NO. 2

S 

Action tremors +

FEVER SPIKES +

O

Pt c/c/c 

Bp - 120/70 

PR - 101

RR- 22

Temp-99.5

Spo2 - 94 at room air 

A

FLARE UP SLE WITH 

LUPUS NEPHRITIS 

CNS LUPUS VASCULITIS 

P

1) Iv fluids NS @30ml/hr 

2) inj methyl Prednisone 750mg in 100ml NS IV OD 

3) INJ. CEFTRIAXONE 1GM IV/BD

4) INJ. PAN 40 MG IV/OD

5) INJ. LASIX 40 MG IV OD

6) INJ.NEOMOL 1GM IV/SOS

7) INJ. DERIPHYLLIN 100MG IV/BD

8) INJ. TRAMADOL 100MG IN 100 ML NS IV/BD 

9) TAB HCQ 200 MG PO/OD

10) TAB. PREDNISOLONE 30MG/PO/BD

11) TAB. DOLO 650 MG PO/TID

12) NEB . BUDECORT P/N 12TH HRLY

13) BP, PR, TEMP, 4TH HRLY CHARTING 

3/10/22

ICU BED NO. 2

S 

B/l pedal edema subsided

COUGH +

Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLYSolved 

8) IV fluids NS @50 ml/hr 

9) inj methyl Prednisone IV OD 

10) tab hcq200mg po od 

11) oint t bact l/a bd 

12) neosporin powder for l/a 

4/10/22

ICU BED NO. 2

S 

B/l pedal edema subsided

COUGH +

Pt c/c/c 

Bp - 110/70 

PR - 125

RR- 29

Temp-98.6

Spo2 - 94 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)INJ CEFTRIAXONE 1GM IV BD

2)INJ PAN 40 MG IV OD 

3) INJ LASIX 40 MG IV BD 

4) INJ DERIPHYLLIN 100MG IV BD 

5) INJ NEOMOL 1GM IV SOS 

6) TAB PREDNISOLONE 50 MG PO BD

7) NEB BUDECORT 12TH HOURLYSolved 

8) IV fluids NS @50 ml/hr 

9) inj methyl Prednisone IV OD 

10) tab hcq200mg po od 

11) oint  t bact l/a bd 

12) neosporin powder for l/a

08/10/22

S 

No fever spikes 

Pt c/c/c 

Bp - 120/90 

PR - 74 

RR- 16

Temp-98

Spo2 - 98 at room air 

A

Falreup of SLE 

LUPUS NEPHRITIS

CNS vasculitis 

P

1)TAB. PAN 40 MG PO OD 

2)TAB. MCQ 200MG/PO/OD

3) TAB PREDNISOLONE 20 MG PO BD

4) TAB. AZORAN 50 MG PO BD 

5) TAB. WARFARIN 5MG PO OD 

6) TAB. WARFARIN 5MG PO OD 

6) SYP. DULPHALAC 15 ML / PO/ TID 

7) OINT - T - BACT L/A BD 

8) CEBHYDRA LOTION L/A BD 

9) NEOSPORIN POWDER L/A

Discussion around the patient

1. Supranuclear bulbar paralysis, a rather more accurate term, is due to an upper motor lesion caused by bilateral disturbance of the corticobulbar tracts. The corticobulbar tracts exert supranuclear control over brainstem motor nuclei and are involved in the muscular movement of the head and neck. They originate from pyramidal cells (Betz cells) in the motor cortex and terminate at cranial nerve nuclei within the brainstem. These nuclei control mastication, deglutition, and speech. Pseudobulbar palsy is characterized by dysarthria, dysphagia, facial and tongue weakness, and emotional lability.[1][2] Any condition which damages bilateral corticobulbar pathways can cause pseudobulbar palsy.

Many pathological conditions can lead to pseudobulbar palsy. These include traumatic brain injury, neoplasm, vascular lesions, metabolic abnormality, or neurological disease. Pseudobulbar palsy is one of the severe complications of cerebrovascular diseases.[2][3]

Rare causes : 

Central pontine myelinolysis

Methotrexate

B/L thalamic infarcts

Neurocysticercosis

PML

Cerebral malaria

Bacterial Endocarditis

Loss of cerebellar modulation (cortico-pontocerebellar pathways) causing emotional dysmetria and disinhibition owing to lesions of corticobulbar volitional pathways are the main pathogenesis explained for pseudobulbar apathy

5. The sequelae reported after viral encephalitis can involve cognitive impairments, motor dysfunction, and epilepsy.Studies of patients who had been diagnosed with viral encephalitis due to HSE have demonstrated sequelae such as speech disorders, memory, and cognitive impairment, personality disorders, and epilepsy (Sellner and Trinka, 2012; Fruchter et al., 2015; Klein et al., 2017). It is vital to notice that the development of epilepsy has been reported 8 years after the onset of the encephalitis, and in nearly 60% of the patients infected with HSV(Sellner and Trinka, 2012; Bonello et al., 2015).

https://www.ncbi.nlm.nih.gov/books/NBK553160/#:~:text=Pseudobulbar%20palsy%20is%20due%20to,tongue%20weakness%2C%20and%20emotional%20lability

https://acrobat.adobe.com/link/review?uri=urn:aaid:scds:US:fd28aca6-a650-371c-9b98-c5221498cd21

Brisk jaw jerk in pseudobulbar palsy

https://youtube.com/shorts/EIWy3__avhY?feature=share

Glucocorticoid in SLE

https://www.mdpi.com/2077-0383/9/9/2709/htm

"The activation of the non-genomic pathway starts at doses >100 mg/day of prednisone or equivalent. This pathway is especially sensitive to methylprednisolone (MP) and dexamethasone, which have non-genomic effects up to five times more potent than genomic ones [8]. "

We'll change to Methylpred sir?

"The “classical” standard 1 mg/kg/day prednisone dose is not supported by either basic pharmacology or clinical evidence (Figure 1) [19,20]. It is unlikely that anti-inflammatory effects increase significantly after prednisone doses have reached 30–40 mg/day, since such doses already result in a saturation of almost 100% of the genomic pathway [12,19]. Recent data suggest that higher initial doses of prednisone are associated with higher cumulative doses [21] with the well proven result of increasing damage accrual [1,22,23,24,25]. "

Have to I guess.

"The “Rituxilup” schedule, which consisted of rituximab and MP, followed by maintenance treatment with mycophenolate mofetil and no oral steroids, resulted in 72% of patients with LN class III, IV, or V eventually achieving complete remission within a median period of 36 weeks [32]. "

"In 2018, Danza et al. compared the efficacy and rates of infections among patients with several autoimmune conditions, including SLE, treated with MP pulses, for a total dose over three days ≤1500 mg, <1500 to ≤3000 mg and >3000 mg [19]. No differences among the different doses were seen in patients achieving complete response, partial response, or no response. No patients in the ≤1500 mg group suffered infections, vs. 9.1% in the high dose group. " 

Or dexa if there are affordability constraints. 

Unfortunately there aren't many trials with dexa comparing this cheaper alternative with expensive MP