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ADISCUSSANTS:

CASE
Romero,
Jiesta Anna Monica
PRESENTATION
SOUTHWESTERN UNIVERSITY
School of Medicine

Department of Internal Medicine

Ongayo, Stephanie Kristie


Campugan, Harjarra Kate
Salazar, Bea Caressa
Abraham, Leonard
Ghimire, Deepak
Artiaga, Narlou

GENERAL DATA

A case of V.C.

19 y.o

Female

Single

Filipino

Cebu City

Admitted for 2nd time


at SHH

CHIEF COMPLAINT

On and off fever

HISTORY OF PRESENT ILLNESS

3 days PTA

Intermittent fever (undocumented)

Epigastric pain

Rash on face and lower extremities

Self-medicated with Paracetamol 500mg


tab every 4 hrs

HISTORY OF PRESENT
ILLNESS

2 days PTA

Intermittent fever

Paracetamol 500mg tab every 4 hrs was


continued

HISTORY OF PRESENT
ILLNESS

Hours PTA

Sought consultation in SHH-OPD

CBC and U/A were requested

CBC

CBC

RESULT

WBC

REF.

2.9 x 103/mm3

4.4-11.0

NEU

61.1% x 103/mm3

37-80

LYM

29.3% x 103/mm3

10-50

MON

6.8% x 103/mm3

0-12

EOS

2.0% x 103/mm3

0-7

BAS

0.4% x 103/mm3

0-2.5

RBC

3.78 x 109/mm3

4.5-5.10

HGB

9.3 g/dl

12.3-15.3

HCT

30.0 %

35.9-44.6

MCV

79 pg

80-96

MCHC

31.1 g/dl

27.5- 33.2

RDW

13.0 %

11.6- 14.8

PLT

94 x 103/mm3

150-450

MPV

8.3 um3

6.0-11.0

URINALYSIS
URINALYSIS

RESULT

REFERENCE VALUE

MACROSCOPIC EXAMINATION
COLOR

YELLOW

TRANSPARENCY

TURBID

PH
SPECIFIC GRAVITY

6.5
1.015

1.003 1.035

CHEMICAL PROPERTIES:
PROTEIN (albumin)

3+

NEGATIVE

LEUKOCYTES

NOT DONE

NEGATIVE

BLOOD / Hb

4+

NEGATIVE

MICROSCOPIC PROPERTIES:
WBC

5-8 / HPF

0-5/HPF

RBC

25-30/ HPF

0-2/HPF

BACTERIA

FEW

PAST MEDICAL HISTORY


Has a history of Bronchial Asthma (1999)

No maintenance medications

Has no known drug or food allergy

No previous surgical history

PERSONAL & SOCIAL


HISTORY
Non-smoker

Non-alcoholic beverage drinker

No history of illicit drug use

FAMILY HISTORY

No known heredofamilial diseases

MENSTRUAL & SEXUAL HISTORY


Menarche at 14 years old

Regular cycle of 5 days duration

Uses 3-4 pads/day

Associated with dysmenorrhea

PHYSICAL EXAMINATION
General survey: Awake,Coherent, Afebrile , Not
in respiratory distress
Vital signs:

BP- 120/80 mmHg

RR- 20 cpm

HR- 86 bpm

Temp - 36.4 0 C

O2 sat- 97%

PHYSICAL EXAMINATION

Skin: Warm, good turgor, (+) rashes on face and


lower extremities
HEENT: Anicteric sclera, pink palpebral conjunctiva,
(-) nasal discharges, (+) dry lips, (-) LAD , (+) Oral
ulcers

PHYSICAL EXAMINATION

C/L: Equal chest expansion, clear breath sounds

CVS: Distinct heart sound, (-) murmur

ABDOMEN: Flat, normoactive bowel sound, soft, (+)


epigastric tenderness

PHYSICAL EXAMINATION

GUT: (-) Kidney punch sign


EXTREMITY: Full range of motion , (-) edema,
(-) cyanosis, Capillary refill time <2 sec, strong
peripheral pulse

NEUROLOGIC EXAMINATION

Cranial nerves: intact

Motor system: intact

Motor strength: 5/5

Cerebellum: intact

Sensory: intact

Meningeal signs: (-)

SEROLOGY:
SEROLOGY:

REFERENCE

DIRECT ANTIGLOBULIN TEST

POSITIVE (+1)

NEGATIVE

INDIRECT ANTIGLOBULIN TEST

NEGATIVE

NEGATIVE

ANTISTREPTOLYSIN O (ASO) TITER

NEGATIVE

COMPLIMENT (C3)

0.10 g/L

( ref 0.9-1.9 g/L)

ALBUMIN

21.4 g/L

39.7 49.4 g/L

CREATININE

0.88 mg/dL

0.51 0.95 mg/dL

ALT (SGPT)

55 U/L

< 33 U/L

SODIUM

140.3 mmol/L

136 145 mmol/L

POTASSIUM

3.9 mmol/L

3.5 5.1 mmol/L

ERYTHROCYTE SEDIMENTATION RATE

35 mm/Hr

0 20 mm/Hr

RETICULOCYTE COUNT

1.5 %

0.5 1.5 %

AT 1:1 DILUTION OR LESS THAN 200 IU/ml

BLOOD CHEMISTRY:

HEMATOLOGY:

PERIPHERAL BLOOD SMEAR

Microcytic hypochromic anemia

Slight anisopoikilocytosis

Leukopenia (with relative neutrophil predominance)

Thrombocytopenia

CHEST X-RAY

Mild Cardiomegaly (CTR 53%)

Pneumonitis, Right Mid-lung Field


Insert picture

WHOLE ABDOMEN
ULTRASOUND
Normal abdominal findings

Incidental note of minimal bilateral pleural


effusion.

URINE TEST
Protein, total urine: 139.1mg/dl

Creatinine, urine random: 47 mg/dl

Protein Creatinine Ratio : 10.35

ECHOCARDIOGRAPHIC
REPORT

Normal left ventricular dimensions with


adequate wall motion and contractility
Left ventricular systolic function ejection
fraction of 74%

ISSUES

HISTORY OF PRESENT ILLNESS

3 days PTA

Is the pain severe? Is it persistent ? Are


there(undocumented)
other associated features like
fever
nausea, vomiting ?

Intermittent

Epigastric pain

(+) rash on face and lower extremities

the rash originate


?
Self-medicatedWhere
with did
Paracetamol
500mg
tab
every 4 hrs

HISTORY OF PRESENT ILLNESS

3 days PTA

Intermittent fever (undocumented)

Epigastric pain

(+) rash on face and lower extremities


Is there any relief
to the patient?

Self-medicated with Paracetamol


500mg
tab
every 4 hrs

PHYSICAL EXAMINATION
General survey: Awake, Coherent, Afebrile , Not in respiratory
distress
Vital signs:

BP- 120/80 mmHg

HR- 86 bpm

RR- 20 cpm

Temp - 36.4 0 C

O2 sat- 97%

1. Is the patient ambulatory or


wheelchair-borne?
2. What is the built of the
patient or the BMI?

PHYSICAL EXAMINATION
General survey: Awake, Coherent, Afebrile , Not in respiratory
distress
Vital signs:

BP- 120/80 mmHg

HR- 86 bpm

RR- 20 cpm

Temp - 36.4 0 C

O2 sat- 97%

Whats the usual range of B.P ?

PHYSICAL EXAMINATION

C/L: Equal chest expansion, clear breath


sounds
CVS: Distinct heart sound, (-) murmur

Is It direct and rebound


ABDOMEN: Flat, normoactive
tenderness ? bowel sound,

soft, (+) epigastric tenderness

SALIENT FEATURES

19 y.o single, female

History of 3 days fever

Epigastric pain & tenderness

Oral ulcers

Rash on face and lower extremities

Minimal bilateral pleural effusion


.

SALIENT FEATURES

Anemia, thrombocytopenia and leucopenia

Proteinuria and hematuria

Positive Direct Coombs test

Low serum complement

DIFFERENTIAL DIAGNOSIS
Salient features

Systemic Lupus
Erythematosus

Drug-induced
Lupus

Parvo B19
Virus infection

Dengue
Fever

DENGUE INFECTION

Presents with febrile illness

Body muscle and joint pain

Body malaise & fatigue

Autoimmune features like (+) Direct Coombs test

Hematological disorders (thrombocytopenia,


leucopenia) in endemic area

DENGUE INFECTION
RULE IN

Lives in endemic area


Presents as febrile illness of 3-5 days
(+) Rashes, epigastric pain
(+) Pleural effusion
(+) Thrombocytopenia/ leucopenia
(+) Low complement level
(+) Variable autoimmune features

RULE OUT

Common in 7-15 year old children


(-) muscle & joint pain
Oral ulcers are rare
Autoimmune features in dengue are
not well recognized
Proteinuria is not explained

Salient features

Systemic
lupus
erythematous

Drug induced
lupus

Parvo B19
virus infection

Dengue
infection

PARVO B19 VIRUS INFECTION

Parvovirus is a small, single-stranded DNA virus.


Infects children more commonly then adults via
respiratory droplets and cause flu like symptoms
Clinical manifestations in adults include fever,
rash, arthropathy & hemolytic or aplastic anemia.
Diagnosis is clinical & may be confirmed by B19specific antibody testing and viral DNA testing.

PARVO B19 VIRUS INFECTION


RULE IN

RULE OUT

Epigastric pain occurs less


Most common feature in adults is
arthopathy (-)
Rashes on extremity are not common
(-) Travel history
Retic count of 1.5 % makes aplastic
anemia unlikely .

Common in childhood and teenagers


(+) fever , facial rashes, oral ulcers
(+) Abdominal pain
Proteinuria 20 to glomerulonephritis
Anemia, leukopenia & thrombocytopenia

Usually has Positive Direct coombs test


and low complement level

Salient features

Systemic
lupus
erythematous

Drug induced
lupus

Parvo B19
virus infection

Dengue
infection

DRUG INDUCED LUPUS

Agents causing lupus like syndrome are procainamide,


hydralazine, isoniazid, OCP, propylthiouracil
Antihistone antibodies (+) are frequent for drug induced
lupus
Resolves within days to months after withdrawal of the
culprit agents

DRUG INDUCED LUPUS


RULE IN

(+) facial rashes, oral ulcers


Autoimmune features like DAT &
cytopenia
(+) epigastric pain
(+) proteinuria
(+) microscopic hematuria to
nephrotic syndrome

RULE OUT

Equally common in males


and females

No agents triggering lupus are taken


by patient

Salient features

Systemic
lupus
erythematous

Drug induced
lupus

Parvo B19
virus infection

Dengue
infection

SYSTEMIC LUPUS ERYTHEMATOUS (SLE)

Protean autoimmune disease most common in women


of child bearing age
Has non specific organ involvement, but more
commonly affects joints, kidney, skin & CNS.
Drug induced lupus Should be excluded before
diagnosis of SLE
Diagnosis is made using clinical criteria.

SLE Criteria

Any combination of four


or more criteria, with at
least one in the clinical
and one in the
immunologic category,
well documented at any
time during an
individuals history,
makes it likely that the
patient has SLE.

Systemic Lupus International


Collaborating Clinic Criteria for
Classification of SLE

Salient features

Systemic
lupus
erythematous

RULED IN

Drug induced
lupus

Parvo B19
virus infection

Dengue
infection

Most Likely Diagnosis

SYSTEMIC LUPUS ERYTHEMATOUS


(SLE) in FLARE

Clinical
Features
of SLE

Fig. Clinical features of SLE

Pathogenesis of SLE

ROLE OF AUTOANTIBODY IN
SLE

LUPUS NEPHRITIS

Nephritis is the most serious manifestation of SLE


Nephritis and infection are the leading causes of
mortality in the first decade of disease
Renal biopsy is recommended with evidence of
nephritis.

CLASSIFICATION OF LUPUS NEPHRITIS


(International Society of Nephrology and Renal
Pathology Society)

FINAL DIAGNOSIS

SLE IN FLARE
(Lupus nephritis class IV)

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