NAME: Tumpa Roy

AGE: 21 years SEX: Female RELIGION: Hindu

MARITAL STATUS: Unmarried

RELIGION: Hindu

BED NO: 21

REG NO: 80336

WARD: Female Medical Ward

DATE OF ADMISSION: 03/ 12/ 19

UNDER DR: Dr. Dipanjan Bandyopadhya

Dr. Samarjit Banik

ADDRESS: Sarkar Para

P.O. Shikarpur
P.S. Rajganj
Dist. Jalpaiguri

CHIEF COMPLAIN DURING ADMISSION: The patient had complain of fever since one
week, pain abdomen since 2 weeks, swelling over neck since 6 months. Also she has non
scarring alopecia due to severe hair fall since last six months.

PRESENT HISTORY OF ILLNESS: Due to increasing complains such as fever and pain
abdomen she was admitted in Belakoba Rural Hospital on 02/12/19 from where she was
referred to North Bengal Medical College and Hospital on 03/12/19 and admitted in Female
Medical Ward.

At present she has no medical disease like diabetes, hypertension. Her blod
reports shows elevated T3, T4 and very low level of TSH.

PAST HISTORY OF ILLNESS: In the past my patient was admitted in Belakoba Rural
Hospital three years before due to complain of fever, headache and bodyache. She has no
significant surgical or medical history besides this.

FAMILY HISTORY: There is no history of any significant medical illness in the family
such as diabetes, hypertension, Systemic Lupus Erythematosus etc

PERSONAL HISTORY:

Education: Studied upto class IV

Occupation: Unemployed
Support system: She is looked after by her parents who work as labours.
Any personal habits: She has no personal habits of taking alcohol, smoking etc
 .

DIET HISTORY: She is non - veg. She takes fish and meat once a week. She takes fruit
sometimes only.She has a poor appetite.

DRUG HISTORY: she has no history of regular intake of any kind of drug.

MENSTRUAL HISTORY

Age of menarche: 15 yrs

Mesntrual cycle ( regular/ irregular): regular cycle
Flow( Normal / heavy/ scant): scant
Dysmenorrhoea ( present / absent): sometimes present

BRIEF SOCIO ECONOMIC HISTORY:

 No of family members: five
 Health status of family members: Fair
 Total family income: Rs 8000 per month approx
 Dietary habits: Non veg
 Housing condition: Kutcha house
 Water supply: Well
 Type of toilet: Sanitary latrine

NURSING ASSESSMENT

AREAS OF ASSESSMENT DATE OF ASSESSMENT: 08 /12/19

EMOTIONAL STATE
Cooperative
Anxious/ Calm / Angry / Cooperative /
Fearful / Restless / Withdrawn

Neck Swelling of thyroid gland visible and according to

patient it developed since six months back.
CENTRAL NERVOUS SYSTEM

Level of consciousness
Alert/ drowsy/ confused/ semiconscious/ Conscious
comatose

Oriented to Time Oriented

Place Oriented
Person Oriented

Relevant
Speech ( Relevant / irregular / slurred /
aphasia)
Adequate
Sleep
( Adequate / disturbed )

RESPIRATORY SYSTEM
Chest movement Bilateral
(Unilateral / Bilateral / Absent )

Respiratory pattern Normal

(Normal / dyspnea /Orthopoea/
Tachypnoea/ Bradypnoea /Paroxysmal
nocturnal dyspnoea

Respiratory rate 16 br/ min

Air entry Bilaterally equal

Bilaterally equal / diminished specify
(R) (L) lung

Breathe sounds Normal

(Normal / rales / rhonchi / wheeze)

Cough Absent

Oxygen on flow Absent

CARDIOVASCULAR SYSTEM

Heart rate 146 bt / min

Blood pressure 130/ 70 mm of Hg

Heart sounds S1, S2 audible. No murmur and no other heart sound.

SpO2 97%

Neck vein distension Absent

Normotension / Hypertension / Normotensive

Hypotension

Chest pain Absent

GASTRO INTESTINAL SYSTEM

Mouth Clean
(Clean / Sordes / Halitosis)

Teeth ( Clean / Plague / loose) Clean/ no carries

Nausea/ Vomitting Absent

Tongue (Clean / coated) Tongue clean

Oral ulcers Absent

Nutrition route Oral route

Peristalsis Present

Constipation / diarrhoea / malena Absent

Abdominal distension Absent

INTEGUMENTARY SYSTEM

Skin ( intact / break down / rash / Mild rash covering the bridge of nose and cheeks.
blister/ infection / specify site)

Cyanosis Absent

Capillary refill ( < 3 sec ) < 3 secs

Peripheries ( Warm / Cold ) Warm

Oedema ( site) Absent

Nails clubbing Absent

Icterus Absent

Temperature Afebrile
Febrile / afebrile
Patchy type of hair loss in some areas. Patient has cut
Scalp her hair short.

Eyes Bright

Nose Patent. No discharge. Nasolabial furrow present.

 Ear Adequate hearing, No discharge

MUSCULOSKELETAL SYSTEM

Joints ( mobile / stiff / painful / Absent

contracture)
Ambulant
Ambulant

GENITOURINARY SYSTEM

Voids freely / catheter Voids freely

Haematuria / Retension / Incontinence / Absent

Sediments

Burning micturation Absent

INTRODUCTION
The immune system normally fights off dangerous infections and bacteria to keep the body
healthy. An autoimmune disease occurs when the immune system attacks the body because it
confuses it for something foreign. There are many autoimmune diseases, including systemic
lupus erythematosus (SLE).
The term lupus has been used to identify a number of immune diseases that have similar
clinical presentations and laboratory features, but SLE is the most common type of lupus.
People are often referring to SLE when they say lupus.

DEFINITION OF LUPUS.

Systemic lupus erythematosus (SLE) is an autoimmune disorder characterized by

antibodies to nuclear and cytoplasmic antigens, multisystem inflammation, protean clinical
manifestations, and a relapsing and remitting course. More than 90% of cases of SLE occur
in women, frequently starting at childbearing age.

Systemic lupus erythematosus (SLE) is a chronic autoimmune, multisystem affecting

disease that causes inflammation in connective tissues, such as cartilage and the lining of ...
joints, kidneys, brain,skin other organs. Immune complexes and other immune system
constituents combine to from complement that is deposited in organs, causing inflammation
and tissue necrosis.

SLE is a chronic disease that can have phases of worsening symptoms that alternate with
periods of mild symptoms. Most people with SLE are able to live a normal life with
treatment.

ETIOLOGY OF SYSTEMIC LUPUS ERYTHEMATOSUS

IN BOOK IN MY PATIENT

The cause of SLE is not clear. However some In my patient the cause is unknown.
potential triggers include the following:-

Genetic factors: It is thought to Unknown

involve genetics together with environmental
factors. Among identical twins, if one is
affected there is a 24% chance the other one
will be as well.

Hormonal factors; Female sex hormones. Hormone. Her blood test shows TSH low as
More than 90% of cases of SLE occur in 0.005 u IU/ ml.( 5/12/19)
women, frequently starting at childbearing
age.

Environmental factors: Sunlight, She has to work outside in sun also in her
smoking, vitamin D deficiency, and certain home surroundings.
infections, are also believed to increase the
risk. The mechanism involves an immune
response by auto antibodies against a person's
own tissues These are most commonly anti-
nuclear antibodies and they result
in inflammation. Diagnosis can be difficult
and is based on a combination of symptoms
and laboratory tests. There are a number of
other kinds of lupus
erythematosus including discoid lupus
erythematosus, neonatal lupus, and subacute
cutaneous lupus erythematosus.

Certain medications: medications such as No history of any regular medicine intake.

hydralazine (Apresoline), procianamide
(Pronestyl), Isoniazid (INH), chlorpromazine
(Thorazine), and some antiseizure
medications, have been implicated in
chemical or drug induced SLE.

CLINICAL MANIFESTATION

IN BOOK IN PATIENT

SLE is an autoimmune disease and can effect

any body system. General symptoms include
fever, weight loss. The other manifestation
are as follows:-

Musculoskeletal system:
 Polyarthralgia with or without joint Absent
erosion.
 Arthritis ( synovitis)
 Joint swelling, tenderness,pain on
movement.

Integumentary system:
 Acute cutaneous lesion consisting of Mild rash covering the bridge of nose and
a butterfly shaped rash across the cheeks
bridge of the nose and cheeks.The
skin rash is provoked by sunlight or
artificial UV light.( Malay rash)

 Painless oral ulcer which may involve

the buccal mucosa or hard palate. Oral ulcer absent.

 Non scarring alopecia in the scalp.

Present

Gastrointestinal symptoms:
absent
 Throat ulcers reflecting
Mild lower abdomen pain
gastrointestinal involvement.

Cardiovascular system:
Absent
 Pericarditis
Absent
 Myocarditis
 Respiratory system Absent
 Pleural effusion

Haematopoetic system
 Moderate to severe anaemia Hb 10.4 g/dl (4/12/19). Patient looked pale.
 Thrombocytopenia Platelet count reduced on smear
 Leukocytosis Not known
 Leukopenia Not known
ANA test not done.
 Positive Anti Nuclear Antibody
(ANA)

Renal system
Absent
 Nephrotic syndrome
 glomerular nephritis, typically with
proteinuria and erythrocyturia
(particularly dysmorphic
erythrocytes)
Seizures/ chorea absent.
Neurologic system
 Seizures Patient was depressed because she expressed
 Chorea her worries by crying and stating that no
 Depression one will marry her and she will be a burden
 Behavioural changes, including for her family.
manifestations of neurosis or Other behaviour pattern was normal.
psychosis ( Neuro- psychiatric lupus)

DIAGNOSTIC ASSESSMENT:

SL IN THE BOOK IN THE PATIENT

NO
1 A high erythrocyte sedimentation rate is
characteristic for active SLE.
2 C-reactive protein (in suspected
infection or pleurisy) is usually normal
or only slightly elevated.
ESR done on 05/12/19 and report was high
than normal ie. 25.00 mm after 1 hour.
(normal range is 00 – 07 mm in 1 hour)
C – reactive protein was normal
Result: 1.0 mg/dl
(Normal range upto 5.0 mg/ dl)

3 Differential blood count may reveal

 cytopenias such as thrombocytopenia
and/or leukopenia and lymphopenia, as
well as further hematological changes
such as autoimmune hemolytic anemia.  angiotyping.
4 Renal parameters
 Creatinine
 Urine status and sediment
5 Antinuclear antibodies (ANA) (Hep – 2
cell test with fluorescence pattern).
Done on 05/12/19
Hb% = 10.4 gm/dl
RBC = microcytic, hypochromic with
Platelet reduced on smear
Done on 03/12/19
Creatinine = 0.6 mg/dl (Normal range 0.6-
1.2 mg/dl)
Na+ = 137.5 mg/dl ( 135- 145 mg/dl)
K + = 4.0 mg/dl ( 3.5 – 5 m mol/ lt)
Advised but not done due to some
unavoidable circumstances.

ORGAN-SPECIFIC DIAGNOSTICS
AS REQUIRED

1  Skin/oral mucous membrane

Not done
 Biopsy: histology,
immunofluorescence if indicated
2  Joints

 Conventional X-ray Not done

 Arthrosonography
 Magnetic resonance imaging
(MRI)

3  Muscle

 Creatine kinase Not done

 Electromyography
 MRI
 Muscle biopsy
4
 Kidney

 Sonography Not done

 Renal biopsy

5
  Lung/heart Not done
 Chest X-ray
 Thoracic high-resolution
computed tomography (HR-CT)
 Lung function test including
diffusion capacity
 Bronchoalveolar lavage
 (Transesophageal)
echocardiography
 Cardiac catheterization
 Cardiac MRI
 Myocardial scintigraphy
6  Coronary angiography

 Eye Not done

Funduscopy/special investigations in
7 patients on antimalarials

 Central and peripheral

nervous system

 Electroencephalography Not done

 Primarily cranial MRI, special
MRI techniques if indicated
 Computed tomography
 Cerebrospinal fluid analysis
 Transcranial Doppler/
angiography
 Neuropsychiatric examination
 Measurement of nerve
conduction velocity
*** In my patient USG of Neck was done in
04/06/19 and report was as follows:
 Thyroid heterogeneous bulky with
diffuse increased vascularity.
? Thyroiditis. B/L subcutaneous
lymph node Level II, III, IV

*** USG whole abdomen done on 04/12/19

Report was within normal limits,

MEDICAL MANAGEMENT
Treatment of SLE includes the management of acute and chronic disease. Although SLE can
be life threatening, advances in treatment have led to improved survival and reduced
morbidity. Acute disease requires interventions directed at controlling increased disease
activity or exacerbations that can involve any organ system. Disease activity is a composite
of clinical and laboratory features that reflect active inflammation secondary to SLE.
Management of the more chronic condition involves periodic monitoring and recognition of
meaningful clinical changes requiring adjustments in therapy.
The goals of treatment include preventing progressive loss of organ function, reducing the
likelihood of acute disease, minimizing disease related disabilities, and preventing
complications from therapy. Management of SLE involves regular monitoring to assess
disease activity and therapeutic effectiveness.

IN THE BOOK IN THE PATIENT

The pharmacologic therapy for SLE is based
on the concept that local tissue inflammation In my patient the treatment she was
is mediated by exaggerated or heightened getting is-
immune responses, which can vary widely in
intensity and require different therapies at 03/12/19 ( On admission)
different times. The following drugs are  Inj Ceftriaxone 1gm IV BD
used:-  IVF with NS @ 8 hourly
 Inj Pan 40 IV OD
CORTICOSTERIOD THERAPY: They are  Inj PCM 650 mg TDS
used topically for cutaneous manifestations,  Inj Ondem 4 mg IV TDS
in low oral doses for minor disease activity
 Tab HCQ ( Hydrochloroquine)
and in high doses for major disease activity.
300mg HS.
Glucocorticoids are the mainstay of treatment
Order changed on 07/ 12/ 19
in SLE, especially at the beginning of a flare.
 Tab Prednisolone 40 OD AC
They have strong anti-inflammatory effects
 Tab CaCo3 (500) BD PC
on both acquired and innate immune
 Tab Ibrufen 400 mg BD AC
pathways. They inhibit B and T cell
responses and effector functions of  Tab Pan 40 BBF
monocytes and neutrophils through inhibition
of NF-κB activity.[5] In lupus,
glucocorticoids are typically neutrophils
administered orally on a daily basis. When
doses greater than 60 mg per day are
required, patients may receive intravenous
methylprednisolone pulse therapy (30 mg
/kg, maximum 1 g /day) although such
treatment has not been shown to be more
effective than doses of 100 to 200 mg daily
and may increase toxicity.

ANTIMALARIAL MEDICATIONS: Tab HCQ ( Hydrochloroquine) 300mg HS

Antimalarials remain as first line treatment
for patients with mild SLE along with
nonsteroidal anti-inflammatory drugs.
Hydroxychloroquine is effective in the
treatment of mild SLE manifestations as well
as in preventing the occurrence of new mild
SLE manifestations, but it is ineffective in
preventing the occurrence of severe SLE
manifestations.Antimalarial medicines are
effective for managing cutaneous,
musculoskeletal and mild systemic features
of SLE.

NSAIDS ( NON STERIODAL ANTI- Tab Ibrufen 400 mg BD PC

INFLAMMATORY DRUGS): The
NSAIDS are used for minor clinical
manifestation along with corticosteroids in an
effort to minimize corticosteroid
requirements.
Not prescribed in my patient.
IMMUNOSUPRESSIVE AGENTS: These
medications ( cyclophosphamide,
azathioprine, mycophenolic acid and
methotrexate) are reserved for patients who
have serious form of SLE that have not
responded to conservative therapies.

MONOCLONAL ANTIBODIES Not prescribed in my patient

(IMMUNOTHERAPY): Monoclonal
antibody is a type of protein made in the
laboratory that can bind to substances in the
body, including cancer cells. A monoclonal
antibody is made so that it binds to only one
substance. A number of monoclonal
antibodies (mAb) are now under
investigation in clinical trials to assess their
potential role in
Systemic Lupus Erythematosus (SLE). The
most frequently used mAb is rituximab,
which is directed against CD20, a membrane
protein expressed on B lymphocytes.
Monoclonal antibodies like rituximab
(Rituxan) and epratuzumab ( humanized anti-
CD22 antibody) have shown good
therapeutic results in clinical trials.

NURSING MANAGEMENT

 The disease or its treatment may produce dramatic changes in appearance and
considerable distress for the patient. The changes and the unpredictable course of SLE
necessitate expert assessment skills and nursing care with sensitivity to psychological
reactions of the patient.
 The nurse must encourage the patient to participate in support groups which can
provide disease information, daily management tips and social support.
 Health advice should be given to avoid sun exposure and encourage the use of sun
glass, scarfs, clothing covering body parts and sunscreen to protect from sunlight.
 Because of risk of involvement of systemic involvement, including renal and
cardiovascular effects, the nurse should help patients understand the need for routine
periodic screenings as well as health promotion activities.
 The nurse must instruct the patients about the importance of continuing prescribed
medications and address the changes and potential side effects that are likely to occur
with their use.
 A dietary consultation may be indicated to ensure that the patient is knowledgeable
about dietary recommendations, given the increased risk of cardiovascular disease,
including hypertension and artherosclerosis.