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

First admission discharge summary

Age/Gender : 21 Years/Female

Address :

Discharge Type: Relieved

Admission Date: 27/09/2022 04:57 PM

Date of Operation MLC No

DR.ADITYA [SR] DR.CHARAN[PGY3] DR.DEEPIKA[PGY1]

Diagnosis

SYSTEMIC LUPUS ERYTHEMATOSUS WITH GLOMERULONEPHRITIC FLARE UP OF LUPUS NEPHRITIS ?CATASTROPHIC APLA SECONDARY TO SLE [LIBMAN SACKS ENDOCARDITIS

,CNS THROMBO EMBOLISM, AND RENAL FAILURE]

Case History and Clinical Findings

20 YR OLD FEMALE CAME ITH C/O B/L PEDAL EDEMA SINCE 15 DAYS HYPERPIGMENTED MACULES SINCE 15 DAYS

FEVER SINCE 15 DAYS

ABDOMINAL DISTENSION SINCE 8 DAYS DRY COUGH SINCE 7 DAYS

SORE THROAT SINCE 7 DAYS DECREASED APPETITE SINCE 7 DAYS SOB SINCE 5 DAYS

DECREASED URINE OUTPUT SINCE 3 DAYS CONSTIPATION SINCE 3 DAYS

HOPI -20 YEAR OLD FEMALE CAME WITH C/O OF B/L PEDAL EDEMA EXTENDING TILL THE KNEES PITTING TYPE SINCE 15DAYS

 

FOR WHICH SHE GOT MEDICAL HEALTH CHECKUP AND PRESCRIBED SOME MEDICATION [UNKNOWN] THEN HER PEDAL EDEMA GOT RESOLVED ALNG WITH FEVER SHE DEVELOPED HYPER PIGMENTED MACULES ON FACE LATER THEY STOPPED MEDICATIONS AFTER 2 DAYS SHE AGAIN HAD A COMPLAINT OF B/L PEDAL EDEMA AND FEVER ABDOMINAL DISTENSION ASSOCIATED WITH DRY COUGH AND DECREASED APPETITE SHE ALSO HAS COMPLAINTS OF DECREASED URINE OUTPUT AND CONSTIPATION SINCE 3 DAYS

PASSING STOOLS ONCE IN 3-4 DAYS N/K/C/O HTN DM THYROID CAD EPILEPSY TB

PERSONAL HISTORY DIET MIXED APPETITE LOST

BOWEL AND BLADDER MOVEMENTS DECREASED

FAMILY HISTORY NOT SIGNIFICNT

O/E-

PT WAS C/C/C

ON ADMISSION VITALS BP 110/70 MMHG

PR-79 BPM RR-19 CPM TEMP -98.8 F

CVS- APEX BEAT DISPLACED LATERALLY PALPABLE THRILL IN MITRAL AREA

LOUD S2 HEARD IN ALL AREAS NO S3 HEARD

PAN SYSTOLIC MURMUR AT MITRAL AREA

RS-

BAE DECREASED

RT INFRA SCAPULAR CREPTS PRESENT P/A-

 

SOFT NON TENDER WITH EMBILICUS NORMAL SHAPE AND INVERTED XIPHI UMBILICAL LENGTH 15 CM

UMBILICO PUBIC LENGTH 12 CM

ON PALPATION NO ORGANOMEGALY

CNS -B/L UPPER LIMB AND LOWER LIMB

HYPER TONIA WITH EXAGERATED DTR ,ABSENT ANKLE REFLEX PATELLAR CLONUS-

RT SIDE 4+

LT SIDE 3+

MOTOR POWER- 4/5 4/5

4/5 4/5

1/10/22

MMSE - DONE ON 1/10/22 ORIENTATION -

ORIENTED TO DAY,MONTH ,SEASON ,DATE -2 FLOOR ,HOSPITAL,DISTRICT,STATE ,COUNTRY-4 RECALL-2/3

ATTENTION AND CALCULATION-3/4 LANGUAGE -2 OBJECTS-2 SENTENCE-1

3 STAGE COMMAND -3 READING CLOSE YOUR EYES WRITING A SENTENCE -0

MODERATE COGNITIVE IMPAIRMENT COURSE IN HOSPITAL

28/09/22-

NEPHRO REFERAL I/V/O ELEVATED RENAL PARAMETERS AND ANASARCA

REFERAL NOTES-LVTS-,OBSTRUCTION -,HEMATURIA-,PYURIA-,YELLOWIS DISCOLORATION-

,NSAID ABUSE -,NATIVE MEDICATION - ADVICED TO CONTINUE THE SAME TREATMENT 28/09/22-

 

PULMO REFERAL I/V/O WHEEZE ,XRAY CHANGES [BL PLEURAL EFFUSION] ADVICED -INJ AUGMENTIN 1.2 GM IV/TID

INJ.LASIX 40 MG IV/BD NED DUOLIN

BUDECORT 6TH HOURLY IMJ NEOMOL 1GM IV/SOS BETADINE GARGLING TAB AZITHROMYCIN

GENERAL SURGERY REFERAL I/V/O BED SORE [1/10/22]

LE- TWO SMALL ULCERS NOTED EITHER SIDE OF INTERGLUTEAL CLEFT MEASURING 1X1 CM EACH

NO ACTIVE DISCHARGE

FLOOR -GRANULATION TISSUE,NO SLOUGH

EDGE SLOPING EDGES NO SURROUNDING INDURATION MARGINS -BLACKISH

ADVICED -TO MAINTAIN HYGEINE AND KEEP THE AREA DRY OINT T BACT FOR LA

NEOSPORIN POWDER FOR LA FREQUENT POSITION CHANGE AIR BED

29/09/22-

ENT REFERRAL WAS TAKEN I/V/O DYSPHONIA REFRAL NOTES-

O/E OF ORAL CAVITY- MUCOSA PALE TONGUE IS COATED

OROPHARYNX-BL GRADE 2 TONSILLAR HYPERTROPHY ,NO CONGESTION NECK-TRACHEA CENTRAL

LARYNGEAL FRAMEWORK NORMAL LARYNGEAL CREPITUS+

NOSE-

EXTERNAL FRAMEWORK NORMAL CAUDAL DISLOCATION-LEFT ANTERIOS MILD DNS -RIGHT

 

B/L NASAL MUCOSA -PALE TURBINATES AND FLOOR -NORMAL ROOMY NASAL CAVITIES

OE EAR-

B/L TYMPANIC MEMBRANE INTACT .,COL+ DIAGNOSIS-DYSPHAGIA UNDER EVALUATION NO ACTIVE ENT INTERVENTION

30/09/22-

REVIEW NEPHRO REFERAL-

USG KUB SHOWING BULKY LT KIDNEY WITH ALTERED ECHOTEXTURE ADVICED TAB AUGMENTIN

TAB PAN 40 MG OD TAB DOLO 650 MG TID 4/10/22-

DVL REFERAL I/V/O HYPERPIGMENTED MACULES NOTED OVER CHEEKS AND FOREHEAD

,NOSE ,CHIN EAR LOBULE ,RETROAURICULAR REGION [CONCHA SPARED], BOTH FOREARMS,BACK,UPPER CHEST

ORAL CAVITY- N

MULTIPLE HYPERPIGMENTED MACULES NOTED OVER BOTH THE PALMS DIAGNOSIS -POST INFLAMMATORY HYPERPIGMENTATION

ADVICED -CEBHYDRA LOTION LA/BD

REVIEW ENT REFERAL I/V/O DYSPHONIA [13/10/22]

ADVICED TO CONTINUE MEDICATION AS ADVICED BY PHYSICIAN WAIT AND WATCH

FOLLOWED BY SPEECH THERAPY

01/10/2022-

20 F WITH ANASRCA BL PEDAL EDEMA ,PLEURAL EFFUSION ,AND PERICARDIAL EFFUSION - RESOLVING

+RASH HEALED +FEVER

SKIN- HEALED RASHES +PAINLESS EMBOLI LIKE LESIONS [JANEWAY LESIONS] PT APPEARS COMFORTABLE

FEVER SPIKES PERSIST -FEVER CHART ANALYSIS-SEPTIC PTTERN ACTION TREMOR+B/L

 

REDUCTION IN TACHYCARDIA[HR 148->112] LIDLAG

HEALING BEDSORE ON BACK [BUTTOCK AREA]

ON 02/10/22-

ANA PROFILE -ANTI dsDNA +++

ANTI HISTONE ,ANTINUCLEOSOME,ANTI KU AG++

MRI BRAIN- MULTIPLE HYPERINTENSITIES IN BRAIN PARENCHYMA F/S/O-VASCULITIS? USG ABDOMEN -MODERATE ASCITES

SLE DAI SCORE-30 POINTS S/O ACTIVE DISEASE

ON 3/10/22-

TACHYPNEA AND TACHYCARDIA SUBSIDED ACTION TREMOR DECREASED

0N 4/10/22

INJ UNFRACTIONATED HEPARIN 5000IU /IV/STAT

FOLLOWED BY INJ UNFRACTIONATED HEPARIN 5000 IU /SC/QID FOR 3 DAYS[GIVEN FOR 3 DAYS [TILL 6//10/22]]

TAB WARFARIN 5MG /PO/OD IS STARTED

TAB LASIX 40MG PO/BD STARTED ON 12/10/22

BLOOD TRANSFUSION WAS DONE ON 13/10/22

ONE PINT OF A+VE BLOOD WAS TRANSFUSED AFTER DOING THE BLOOD GROUPING AND TYPING AND CROSS MATCHING

TRANSFUSION STARTED AT 7;30 PM AND WAS COMPLETED BY 11;20 PM

HALF AND HOURLY MONITORING OF VITALS WAS DONE DURING THE PROCESS OF TRANSFUSION

PRE TRANSFUSION VITALS AND POST TRANSFUSION VITALS WERE MONITORED,PT WAS STABLE AND NO CHILLS,RIGORS,FEVER,MYALGIA DURING THE TRANSFUSION

 

Investigation

USG IMPRESSION[28/09/2022] MODERATE PERICARDIAL EFFUSION BILATERAL PLEURAL EFFUSION GROSS ASCITES

MRI BRAIN PLAIN WITH CSPINE SCREENING[ON 3/10/22] IMPRESSION-

DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY

MULTIPLE SMALL ACUTE INFARCTS IN BOTH CEREBRAL HEMISPHERES-EMBOLIC SCREENING OF CERVICAL AND DORSAL SPINE APPEARS NORMAL

Treatment Given(Enter only Generic Name)

1] INJ AUGUMENTIN 1.2 GM IV/BD FOR 2 DAYS

2] INJ LASIX 40 MG IV/BD FOR 9 DAYS

3] NEB WITH DUOLIN BUDECORT

4] INJ NEOMOL 1GM IV/SOS

5] TAB AZITHROMYCIN 500 MG PO/OD FOR 2 DAYS

6] BETADINE GARGLES /TID

7] INJ DERIPHYLLINE 100 MG IV /BD FOR 7 DAYS

8] TAB PREDNISOLONE 50 MG PO/BD FOR 3 DAYS[STARTED ON 29/9/22 TO 1/10/22] TAB PREDNISOLONE 30 MG PO/BD FOR 1 DAY[STARTED ON 2/10/22 ]

TAB PREDNISOLONE 20 MG PO/BD FOR 11 DAYS[STARTED ON 3/10/22 ] 9]INJ PAN 40 MG IV/OD

10] INJ CEFTRIOXONE 1 GM IV/BD FOR 7 DAYS

11] INJ TRAMADOL 1 AMP IN 100 ML NA/IV/BD

12] INJ METHYL PREDNISOLONE 750 MG IN 100 ML NS/IV /OD FOR 3 DAYS[2/10/22 TO 4/10/22]

13] TAB HCQ 200 MG PO/OD[STARTED ON 2/10/22]

14] TAB DOLO 650 MG PO/TID

15] OINT T BACT FOR LA /BD

16] NEOSPORIN POWDER FOR LA

17] TAB AZORAN 50 MG PO/BD

18] SYP DULPHALAC 15 ML PO/TID

19] INJ UNFRATIONATED HEPARIN 5000 IU/SC/QID FOR 3 DAYS

20] TAB WARFARIN 5MG /PO/OD

 

21] CEBHYDRA LOTION LA /BD

Advice at Discharge

1] TAB HCQ 200 MG PER ORAL ONCE DAILY

2] TAB PREDNISOLONE 20 MG PER ORAL TWICE DAILY

3] TAB AZORAN 50 MG PER ORAL TWICE DAILY

4] TAB LASIX 40 MG PER ORAL TWICE DAILY

5] SYP SUCRALFATE 10 MLTHRICE DAILY

6] SYP DULPHLAC 15 ML PER ORAL THRICE DAILY

7] OINT TBACT LOCAL APPLICATION TWICE DAILY

8] CEBHYDRA LOTION LOCAL APPLICATION TWICE DAILY

9] NEOSPORIN LOCAL APPLICATION

Follow Up

REVIEW TO GM OPD ON TUESDAYS OR SOS

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:13/10/2022 Ward:AMC Unit:GM 2

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

2nd admission discharge summary:

Age/Gender : 21 Years/Female

Address :

Discharge Type: Relieved

Admission Date: 01/12/2022 02:17 PM

Diagnosis

1. INTRA VENTRICULAR HAEMORRHAGE SECONDARY TO WARFARIN INDUCED

2. SLE(?LUPUS NEPHRITIS)

3. ?AUTOIMMUNE MENINGISM

Case History and Clinical Findings

 

Patient presented with flare up of SLE with Libmann Sachs endocarditis and vasculitic stroke discharged with Tab. Prednisolone 20mg BD, Tab. Azathioprine 50mg BD, Tab. HCQ 200mg OD, Tab. Warfarin 5 mg BD.On 01/12/22 patient presented to OPD with complaints of Headache, vomitings and neck pains since 2-3 days.Patient was apparently normal 3 months ago,then she had b/l pitting type of pedal oedema extending till knees which was relieved on taking medication(unknown).later she developed fever and hyperpigmented macules on face-face was high grade, later she developed b/l pitting tyoe of pedal edem,dry cough,abdomminal distension, decreased appetite and decreased urine output. later all her complaints improved after discharge ( oct 2022 ) and was alright till 3 days back, Then she developed Headache diffuse associated with neck pains which worsened next day following which she developed, vomiting of 3-4 episodes, non bilious and food particles as contents, she told it was not associated with pain abdomen or abdominal discomfort.No fever, no altered sensorium, No blurring of vision, No diplopia, No photophobia or phonophobia.No history of trauma.Vitals at admission :Bp 170/110mmhgPr : 84Spo2 : 99 on RARR : 18 cpmTemp : Afebrile to touch.On examination :Facial puffiness present with stary look. Previous rashes subsided.Echymotic patch noticed on Rt knee.Neck stiffness present associated with Pain.CVS : no raised JVP, Heart sounds unremarkable, previous MR murmur subsided.RS:BAE+,NVBSP/A : soft, nontender bowel sounds present.CNS :MMSE : 30/30HMF : intactCranial nerves : normalMotor: detailed examination will be shared shortly.Exaggerated deep tendon reflexes.With I'll sustained patellar clonus.Persistent nausea and vomiting. After low dose opinoid ( Tramadol ) + antiemeticPersistent neck pain with stiffness.Crcl = 60ml/minFor acute headache and neck pain reduction she was given Naproxen 125mg stat.3/12/22Patient developed Diplopia today. Transient Rt. LR palsy. Started in

inj. 3%NACL to decrease ICP. For 6hrs.Patient attenders councelled regarding this and advised for neurosurgical opinion but due to personal problems they continued treatment here with high risk.4/12/22Diplopia subsided and no fever spikesNeck pain and vomitings subsided.vitals at discharge:no c/o fever,vomitingpt is c/c/cafebrilebp:130/90mmhgpr:80bpmcvs:s1s2+pan systolic murmur+rs:BAE+p/a:soft,NTcns:NADbrief course in hospital:pt was presented to opd by above given complaints .clinical examinations,MRI and other investigations were done and pt was diagonsed as INTRA VENTRICULAR HAEMORRHAGE SECONDARY TO WARFARIN INDUCED WITH

SLE(?LUPUS NEPHRITIS) . 2 units of platlets were transfused and treament was given, after that pts complaints were subsided and pt have been discharged at haemdynamically stable condition

Investigation

MRI BRAIN PLAIN:

-MILD INTRA VENTRICULAR HEMORRHAGE WITH ACUTE Hydrocephalus

-MILD DIFFUSE SUBARACHNOID HEMORRHAGE

-DIFFUSE CEREBRAL AND CEREBELLAR ATROPHY

-GLIOTIC CHANGE IN RIGHT SUPERIOR PARIENTAL LOBULE

 

2D ECHO:

-MILD MR+/AR+:TRIVIAL TR+

-NO RWMA, NO AS/MS

-GOOD LV SYSTOLIC FUNCTIONS

-NO DIASTOLIC DYSFUNCTION,NO PAH/PE

BLOOD CULTURE: NO GROWTH AFTER 24 HR OF AEROBIC INTUBATION

OPHTHALMOLOGY OPINION:

NO RAISE ICT FINDING NOTED ON FUNDUS EXAMINATION

HAEMOGRAM:

ON ADMISSION:

HB:10.2 PCV:33.1 TLC:12,000 RBC:3.47 PLT:4.2 ON 7/12/22:

HB:10.4 PCV:34.7 TLC:16,800 RBC:3.54 PLT:5.40

PT;APTT

ON 1/12: >1MIN;>1MIN ON 3/12: 17SEC;35 SEC ON 4/12: 18;37

ON 5/12: 16;32

ON 7/12: 18;36

ON 9/12: 20;40

Treatment Given(Enter only Generic Name)

DAY-1:

1.T.PCM 500MG PO/TID

2.T.HCQ 200MG PO/BD

3.T.AZATHIOPRINE 50MG PO/BD

4. PREDNISOLONE 20 MG PO/BD

5. INJ.ZOFER 4MG IV/BD

 

6. SYP.SUCRALFATE 15ML PO/BD

7. INJ.TRAMADOL 1AMP IN 100ML NS/STAT

DAY-2

1.T.PCM 650MG PO/TID

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. PREDNISOLONE 20 MG PO/BD

5. INJ.ZOFER 4MG IV/TID

6. SYP.SUCRALFATE 15ML PO/BD

7. INJ.TRAMADOL 1AMP IN 100ML NS/STAT

8. INJ.MONOCEF 2GM IV/STAT

9. INJ VIT K 10MG IV/OD

DAY-3

2 UNITS OF FFP WAS TRANSFUSED

1.T.PCM 650MG PO/TID

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/TID

6. INJ.MONOCEF 2GM IV/BD

7. INJ.TRAMADOL 1OOMG IN 100ML NS/SOS

8. INJ.VIT.K 10MG IV/OD

DAY-4

1.T.PCM 650MG PO/TID

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/TID

6. INJ.MONOCEF 2GM IV/BD

7. INJ.TRAMADOL 1OOMG IN 100ML NS/SOS

8. INJ.PANTOP 40MG IV/OD

 

9.T.NAPROXEN 250MG PO/SOS

10. INJ.VIT-K 10MG/IV/OD

11. INJ.TRANEXA 500MG/IV/BD

12. INJ.MANNITOL 20GM IV/BD

DAY-5

1.T.PCM 650MG PO/SOS

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/SOS

6. INJ.MONOCEF 1GM IV/BD

7. INJ.MANNITOL 20GM IV/BD

8. INJ.PAN 40MG /IV/OD

DAY-6

1.T.PCM 650MG PO/SOS

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/SOS

6. INJ.MONOCEF 1GM IV/BD

7. INJ.MANNITOL 20GM IV/BD

8. INJ.PAN 40MG /IV/OD

DAY-7

1.T.PCM 650MG PO/SOS

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/SOS

6. INJ.MONOCEF 1GM IV/BD

7. INJ.MANNITOL 20GM IV/BD

8. INJ.PAN 40MG /IV/OD

 

DAY-8

1.T.PCM 650MG PO/SOS

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 50MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/SOS

6. INJ.MONOCEF 1GM IV/BD

7. INJ.MANNITOL 20GM IV/BD

8. INJ.PAN 40MG /IV/OD

DAY-9

1.T.PCM 650MG PO/SOS

2.T.HCQ 200MG PO/OD

3.T.AZATHIOPRINE 500MG PO/BD

4. INJ.DEXAMETHASONE 8MG IV/TID

5. INJ.ZOFER 4MG IV/SOS

6. INJ.MONOCEF 1GM IV/BD

7. INJ.MANNITOL 20GM IV/BD

8. INJ.PAN 40MG /IV/OD

Advice at Discharge

1. TAB.ACITROM 1MG PO/OD(1-X-X)

2. TAB.PREDNISOLONE 20MG PO/BD(1-X-1)

3. TAB.AZATHIOPRINE 50MG PO/BD(1-X-1)

4. TAB.HCQ 200MG PO/OD(1-X-X)

5. TAB.PCM PO/SOS

6. TAB.PAN 40MG PO/OD(1-X-X)

Follow Up

REVIEW AFTER 7 DAYS ON SATURDAY TO GENERAL MEDICINE OPD

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:10/12/2022 Ward:MEDICAL WARD

Unit:GM 6

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. Presented 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

[08/09/2024, 20:06] Rakesh Biswas: @⁨Lupus 20F Patient Advocate⁩ 

మీ పేషెంట్ ఇప్పుడు ఎలా ఉన్నారు? ఆమె దగ్గు ఎలా ఉంది?

Mī pēṣeṇṭ ippuḍu elā unnāru? Āme daggu elā undi?

How's your patient now? How's her cough?

[08/09/2024, 20:08] Lupus 20F Patient Advocate: Kk sir epudu maa frnd daggu thaggindhi intlo Pani  chesukuntundi

[08/09/2024, 20:18] Rakesh Biswas: 4th admission updated here: 

https://medicinedepartment.blogspot.com/2024/08/20f-lupus-clinical-complexity-ehr.html?m=1

@⁨Vyshnavi Kims PG 2023⁩ please ask Saidulu to share her 4th admission discharge summary

[08/09/2024, 20:28] Vyshnavi Kims PG 2023: Okay sir

[23/12/2024, 12:48] Rakesh Biswas: Reviewed in OPD just now:

Complains of epigastric pain and vomiting 5 times and hasn't eaten since yesterday morning due to severe anorexia since the vomitings

[24/12/2024, 07:50] Lupus 20F Patient Advocate: Gd mrng sir nd madam yesterday ni8 vomiting 2times

[24/12/2024, 07:53] Pushed1Comm22: Usg report pettu

[24/12/2024, 09:36] Rakesh Biswas: Is she admitted?

[26/12/2024, 13:42] Sai Charan Kulkarni 2020 KIMS Pg: @⁨Lupus 20F Patient Advocate⁩  suffering form pain abdomen currently am unable to answer her cal. Please any volunteer or pg or intern could help her 🙏🏻

[26/12/2024, 13:52] Pushed Communicator 1N22: Unable to call her sir

Some problem from her end i guess

Messaged her

[26/12/2024, 13:55] Sai Charan Kulkarni 2020 KIMS Pg: Also shared patient guardians number to whom I spoke yesterday and today morning

[26/12/2024, 13:57] Pushed Communicator 1N22: Ok sir

She came to op just now

[26/12/2024, 14:17] Rakesh Biswas: Let's admit her. I can review her in the ICU AMC now

[30/12/2024, 13:07] Lupus 20F Patient Advocate: Gd afternoon sir and madam maa frnd kallu vapulu vasthunnae moham kuda

[30/12/2024, 13:41] Patient Advocate 56F Migraine Hypothyroidism 2000: I spoke to this PA and asked about her patient. She was reluctant to talk in detail and was saying nothing. She said her patient was suffering with severe cold and cough since 2-3days and puffy eyes, face and pedal edema also since 2-3 days.

[30/12/2024, 13:48] Sai Charan Kulkarni 2020 KIMS Pg: Kalla photo pettagalava..?

[30/12/2024, 14:21] Rakesh Biswas: Thanks

Looks like her renal proteinuria may have increased.

We'll need to get her serum albumin and urine for 24 hour protein and creatinine

Let's ask her to share the image of her kidney medications

I guess she was on tablet azathioprine and prednisolone and the prednisolone dose had been brought down to the minimum

[30/12/2024, 16:46] Sai Charan Kulkarni 2020 KIMS Pg: Hospital ki ochi Oka 1-2 days undalsi ostadi. 24h urine proteins test cheyali. E test ippudu Chala avasaram. E test batti tablets doses change cheyalsi vuntundi

[30/12/2024, 17:06] Lupus 20F Patient Advocate: Kk sir

[30/12/2024, 19:22] Rakesh Biswas: Please ask her to share her current tablet dosages and when did she taper them off

[30/12/2024, 19:27] Sai Charan Kulkarni 2020 KIMS Pg: Me patient ippudu vade tablets photo pettandi. Enni days nundi e tablets vadtunnaru..?

[30/12/2024, 19:52] Lupus 20F Patient Advocate: 5mg mrng 2.5 nt sir

[30/12/2024, 19:53] Lupus 20F Patient Advocate: Yellow tblt aftter noon sir

[30/12/2024, 19:53] Rakesh Biswas: Yellow tablet packet picture to see name and dose

[30/12/2024, 19:54] Lupus 20F Patient Advocate: 50mg

[30/12/2024, 19:59] Sai Charan Kulkarni 2020 KIMS Pg: AZA 50mg sir

[30/12/2024, 20:08] Rakesh Biswas: Was she always consuming 50 mg or was it reduced after she developed the hydropneumothorax?

[02/01/2025, 08:42] Sai Charan Kulkarni 2020 KIMS Pg: Just received a call from Patient advocate, patient is having constipation with no flatus, No urine output and Generalised body swelling. In apprehension he got a syrup to relieve her constipation but still stools not passed. He will be visiting ER in a while. @⁨Pushed Communicator 1N22⁩  @⁨Pushed1Comm22⁩ @⁨Ajay Reddy 2022 Med PG Kims⁩ @⁨PI Portal Hypertension Project 2022⁩ @⁨Pushed Comm 1AI23⁩ @⁨Harika CKD Anemia 2022 Project PI⁩  please look into this

[02/01/2025, 09:14] Rakesh Biswas: Yes hoping to see her soon. Will be in OPD

[02/01/2025, 09:53] Rakesh Biswas: They can even reach directly to our OPD

[02/01/2025, 11:23] Rakesh Biswas: Reviewed in OPD:

Anasarca

Other findings wnl

Anuric since morning

Constipation since morning 

Plan

Admit in wards

Monitor intake output

[02/01/2025, 11:25] Sai Charan Kulkarni 2020 KIMS Pg: 24h UPCR sir..?

[02/01/2025, 11:25] Rakesh Biswas: Yes once the urine comes out

[02/01/2025, 12:17] Rakesh Biswas: @⁨Vyshnavi Kims PG 2023⁩ she passed 250 ml of urine (her estimate) spontaneously now!

[02/01/2025, 16:36] Sai Charan Kulkarni 2020 KIMS Pg: @⁨Pushed1Comm22⁩  @⁨Pushed Communicator 1N22⁩ patient is having agonising pain abdomen, her advocate is apprehensive about her abdominal distension and pain abdomen. Kindly look into this and update please

[02/01/2025, 16:38] Rakesh Biswas: Oh just now?

She didn't have it in the morning or even afternoon?

She's likely having a post infectious IBS and can be put on Buscopan tablets tid and injection Buscopan sos

[02/01/2025, 16:40] Sai Charan Kulkarni 2020 KIMS Pg: Yes sir 2 min back. He reports pain is worsening.

[02/01/2025, 16:41] Rakesh Biswas: @⁨Vyshnavi Kims PG 2023⁩ share your clinical findings or ask the AMC pg to share here ASAP

[02/01/2025, 16:42] Rakesh Biswas: @⁨Akash Deep Kims 2023⁩ if you are there in AMC just examine her abdomen and share the findings

[02/01/2025, 16:43] Akash Deep Kims 2023: Abdomen is soft and non tender sir

[02/01/2025, 16:44] Rakesh Biswas: And how is her pain now?

[02/01/2025, 16:47] Akash Deep Kims 2023: She is complaining of bloating of abdomen sir 

She did not pass stool since  yesterday 

O/e : abdomnen is soft and no tender 

Bowel sounds present

[02/01/2025, 16:48] Akash Deep Kims 2023: Yes sir after giving inj pantop

[02/01/2025, 16:54] Sai Charan Kulkarni 2020 KIMS Pg: Thank you. Any intervention to relieve her constipation ..?

[02/01/2025, 17:02] Akash Deep Kims 2023: Giving Enema sir

[03/01/2025, 20:11] Rakesh Biswas: @⁨Vyshnavi Kims PG 2023⁩ share the deidentified abdominal ultrasound report here

[03/01/2025, 20:14] Rakesh Biswas: Now check out figure 4 here 👇

https://ajronline.org/doi/10.2214/ajr.174.1.1740107

And use our POCUS device to DIY

[04/01/2025, 16:20] Rakesh Biswas: Reviewed in the afternoon:

Current autoimmune inflammatory indicators: 

24 hour significant proteinuria 1.2 g suggestive of active glomerular inflammation

Persistent bowel symptoms in this admission and thickening on imaging suggestive of possible IBD

Reviewed the major events in the entire history from September 2022:

1st admission with altered sensorium, serositis, nephrotic proteinuria and ANA +++ suggestive of Lupus and started on high dose steroids with azathioprine as adjuvant and unfortunate anticoagulants (thinking of cardiac embolism) 

December 2022 

2nd admission with complications of minor IC bleed due to anticoagulant

Lost to follow up in 2023 till June 2024 

Not sure if she achieved glomerular remission

Stopped all Rx in December 2023

June 2024 presented with flare of arthritis and proteinuria

Restarted steroids and adjuvants and developed pyopneumothorax because of which immunosuppressives were again quickly tapered off to prednisolone 5mg and Azathioprine 50 mg once daily with poor follow up and this time in Jan 2025 she appears to have developed glomerular injury again along with possible IBD this time!

[04/01/2025, 23:51] Himaja 2022 Kims PG: She had libbmans sacks endocarditis

And once she admitted with Cushing also sir

Her PT INR APTT was also deranged back then, PT was in 100 contributed it to warfarin

[05/01/2025, 09:19] Rakesh Biswas: Libmanns sacks endocarditis is not an easy diagnosis and definitely needs histopathological confirmation and in her case as well as most cases that isn't possible and it's largely an autopsy pathology learning point.

Yes she did have side effects of steroids that are very common trade offs unlike her anticoagulant trade off where the benefit risk ratio needed to be better balanced and I would classify it as an over-testing leading to LSE and cerebral embolism diagnosis leading to overtreatment with anticoagulants

Yes the PT INR was the marker of the overtreatment delivered along with the MRI brain hemorrhages that were luckily detected early due to serendipitous sequence of events that brought her back in altered sensorium during her second admission

[05/01/2025, 19:03] pajr.in CEO, NHS Endocrinologist: I remember we did see some vegetations and a profound MR on the echo, first time?

[05/01/2025, 19:08] Rakesh Biswas: Unfortunately the echocardiography video wasn't archived?

[05/01/2025, 19:13] pajr.in CEO, NHS Endocrinologist: I believe it was archived. @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ or @⁨Deepika Kims Med PG 2021⁩ should be aware.

[05/01/2025, 19:14] Sai Charan Kulkarni 2020 KIMS Pg: Missed video but captured this for clinical meet presentation. Her first admission echo image

[05/01/2025, 19:17] Sai Charan Kulkarni 2020 KIMS Pg: https://youtu.be/3o3hx0fYWNo

Retrieved from 

https://mutyapuraghavendra.blogspot.com/2022/09/a-20-year-female-with-pedal-edema-and.html?m=1

[05/01/2025, 19:22] Rakesh Biswas: Thanks

Without the mitral valve Doppler it's difficult to say if the MR visible on CFM is trivial or significant. 

However valvulitis is probable looking at the video. So as mentioned before it's a difficult diagnosis and the probability can only be enhanced with histopathology

[05/01/2025, 19:25] Rakesh Biswas: Not sure about the vegetations although again yes there is a suspicious shadow in the inner surface of pml

[05/01/2025, 19:27] Rakesh Biswas: Fantastic to see this really!

Whatever case reports and data we capture and archive may become more valuable with the passage of time! @⁨Patient Advocate 56F Migraine Hypothyroidism 2000⁩ @⁨Patient advocate 23F Weight Gain⁩ @⁨Inner Strength Engineer1⁩

[08/01/2025, 19:23] Rakesh Biswas: Update:

[08/01, 17:55] PG: Sir....her bp in morning is 160/100

1pm 170/100

5pm 170/100

Does she need any antihypertensive sir??

[08/01, 19:22] PM: Yes

Start tablet Telmisartan as it will also be available from her local PHC

Please share her hourly BP chart

[12/01/2025, 13:08] Rakesh Biswas: Can start Tablet Lasix 40 mg once daily

[12/01/2025, 13:08] Rakesh Biswas: Please share the other medicines this patient is taking

[12/01/2025, 19:30] Lupus 20F Patient Advocate: Vapulu ala thaguthae  sir

[12/01/2025, 19:31] Pushed Communicator 1N22: Ee tablet roju okati veskovali

[12/01/2025, 19:34] Rakesh Biswas: Tablet lasix to tide over the cosmetic crisis 

Prednisolone and azathioprine will take a few weeks to show efficacy

[12/01/2025, 19:39] Lupus 20F Patient Advocate: 40 mg kadu sir 30mg afternoon vesukunta

[12/01/2025, 19:42] Rakesh Biswas: Start taking tablet lasix 40 mg

[12/01/2025, 20:38] Pushed Communicator 1N22: Idhi 

Vere tablet

[17/01/2025, 17:01] Rakesh Biswas: Reviewed the patient today in ICU (forgot to post this earlier)

Has started having severe epigastric abdominal pain again since yesterday 

Along with vomiting 

On examination:

Abdomen soft

Working diagnosis:

Drug induced gastritis

Plan @⁨PI Portal Hypertension Project 2022⁩ @⁨Pushed Comm 1AI23⁩ @⁨Communicating Learner 1N23⁩ 

Hold the tablet prednisolone for a few days

Repeat LFT

Serum creatinine

Urine for 24 hour protein and creatinine 

Temporarily withhold

[17/01/2025, 17:04] Rakesh Biswas: Everytime since last few years when she developed florid proteinuria she would clinically go into remission (although not documented in 24 hour values, the nearest was probably 700 mg recently during last admission when we were battling the ravages of her pyopneumothorax) following which after the steroids were tapered due to the infection, she again developed this florid proteinuria since two weeks which doesn't seem to be responding to the 30 mg of prednisolone this time, which is on the contrary producing side effects!

[20/01/2025, 09:09] Rakesh Biswas: Update?

Is she getting discharged?

Any repeat 24 hour protein creatinine results in this admission?

Is she on physiological doses of her previous 30 mg prednisolone that had to be withheld due to suspected gastritis?

[20/01/2025, 09:10] Rakesh Biswas: @⁨Kundana 2019⁩ who requested entry to this group can you please introduce yourself?

[20/01/2025, 09:21] Pushed Communicator 1N22: Yes sir

Planning for discharge today

Pedal edema and abd distension subsided sir

No pain abdomen nausea and vomitings

She is taking food as before

[20/01/2025, 09:22] Pushed Communicator 1N22: We stopped prednisolone and azathioprine for the last 3 days sir

Shall we put her back on those and discharge today sir ?

[20/01/2025, 09:27] Rakesh Biswas: Calculate the actual GFR using the urinary creatinine. @⁨Durga Krishna 2020 Pg 29f Patient Adv 2⁩ @⁨Inner Strength Engineer1⁩ can you help?

[20/01/2025, 16:18] Durga Krishna 2020 Pg 29f Patient Adv 2: What was her serum creatinine value ??

[20/01/2025, 16:21] PI Portal Hypertension Project 2022: Creatinine is 0.8mg/dl sir

[20/01/2025, 16:24] Rakesh Biswas: But remember for gfr calculation from urinary creatinine (this is not e gfr) you need to use the urinary creatinine, the 24 hour urinary volume and other parameters in the formula

[20/01/2025, 16:24] Durga Krishna 2020 Pg 29f Patient Adv 2: Ok sir.

[21/01/2025, 10:14] Rakesh Biswas: Yesterday's EMR discharge summary to be updated in the case report:

Age/Gender : 23 Years/Female

Address :

Discharge Type: Relieved

Admission Date: 17/01/2025 03:31 PM

Name of Treating Faculty

DR VAMSHI KRISHNA [ASST.PROFSSOR] DR PRACHETHAN PGY3

DR RAVI PGY2

Diagnosis

1. DRUG INDUCED GASTRITIS ? ORAL STEROIDS INDUCED

2. LUPUS NEPHRITIS WITH FLARE

3. INFLAMMMATORY COLITIS

4. K/C/O SYSTEMIC LUPUS ERYTHEMATOSIS [SLE] SINCE 4 YEARS

Case History and Clinical Findings

C/O PAIN ABDOMEN SINCE YESTERDAY NIGHT C/O VOMTINGS SINCE TODAY MORNING HISTORY OF PRESENTING ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1DAYS AGO,THEN SHE DEVELOPED PAIN ABDOMEN SINCE YESTERDAY NIGHT AT EPIGASTRIC REGION TENDERNESS PRESENT ASSOCIATED WITH VOMITINGS SINCE TODAY MORNING THREE EPISODES, NON BILIOUS, NON PROJECTILE,NON BLOOD STAINED ,WATER AS CONTENT

NO AGGRAVATING AND RELIEVING FACTORS ASSOCIATED WITH NAUSEA

H/O PEDAL EDEMA AND FACIAL PUFFINESS SINCE 25 DAYS

NO H/O FEVER, COLD, COUGH, ALLERGIES, CHEST PAIN, PALPITATIONS, SWEATING, SOB, BURNING MICTURITION, CONSTIPATION

PAST HISTORY:

K/C/O SLE , LUPUS NEPHRITIS AND INFECTIVE COLITIS N/K/C/O DM II, TB, EPILEPSY, ASTHMA, CVA,CAD

 

FAMILY HISTORY:

INSIGNIFANCT PERSONAL HISTORY:

SLEEP- ADEQUATE APPETITE-NORMAL DIET-MIXED

BOWEL AND BLADDER MOVEMENTS-REGULAR ADDICTIONS-NIL

GENERAL PHYSICAL EXAMINATION:

TEMPERATURE-AFEBRILE BP-160/100MMHG

PR-156BPM RR-22CPM

SPO2-98%AT RA

MILD BILATERAL PEDAL EDEMA PRESENT [PITTING TYPE]

NO PALLOR, ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY, MALNUTRITION CVS - S1, S2 HEARD, NO MURMURS.

RS- B/L AE - PRESENT, NVBS, NO ADDED SOUNDS.

P/A - SOFT, TENDERNESS AT EPIGASTRIC REGION, NO ORGANOMEGALY, BOWEL SOUNDS PRESENT

CNS-NO FOCAL NEUROLOGICAL DEFICIT LOCAL EXAMINATION:

PER ABDOMENSOFT, TENDERNESS AT EPIGASTRIC REGION, BOWEL SOUNDS PRESENT, NO ORGANOMEGALY

NO GUARDING, NO RIGIDITY NO SCARS

Investigation

Anti HCV Antibodies - RAPID 17-01-2025 05:54:PM Non Reactive HBsAg-RAPID 17-01-2025 05:54:PM Negative

RBS ON 17/1/25 -70 mg/dl. HEMOGRAM ON 17/1/25

 

HAEMOGLOBIN 8.2 gm/dlTOTAL COUNT 9,200 cells/cumm NEUTROPHILS 84 % LYMPHOCYTES 11 % EOSINOPHILS 04 % MONOCYTES 01 % BASOPHILS 00 % PCV 24.2 vol % M C V 84.6 fl M C H 28.7 pg M C H C 33.9 % RDW-CV 15.3 % RDW-SD 47.2 fl RBC COUNT 2.86 millions/cumm

PLATELET COUNT 3.05 lakhs/cu.mm SMEARRBC Normocytic normochromic Light MicroscopyWBC With in normal limits Light MicroscopyPLATELETS Adeqaute Light MicroscopyHEMOPARASITES No hemoparasites seen Light MicroscopyIMPRESSION Normocytic normochromic anemia

LIVER FUNCTION TEST (LFT) 17-01-2025 05:54:PMTotal Bilurubin 1.07 mg/dl 1-0 mg/dlDirect Bilurubin 0.20 mg/dl 0.2-0.0 mg/dlSGOT(AST) 15 IU/L 31-0 IU/LSGPT(ALT) 10 IU/L 34-0

IU/LALKALINE PHOSPHATASE 84 IU/L 98-42 IU/LTOTAL PROTEINS 3.9 gm/dl 8.3-6.4

gm/dlALBUMIN 2.12 gm/dl 5.2-3.5 gm/dlA/G RATIO 1.19

COMPLETE URINE EXAMINATION (CUE) 17-01-2025 05:54:PMCOLOUR Pale yellowAPPEARANCE ClearREACTION AcidicSP.GRAVITY 1.010ALBUMIN +++SUGAR NilBILE SALTS NilBILE PIGMENTS NilPUS CELLS 3-4EPITHELIAL CELLS 2-3RED BLOOD CELLS 3- 4CRYSTALS NilCASTS NilAMORPHOUS DEPOSITS AbsentOTHERS Nil

BLOOD UREA 17-01-2025 05:54:PM 49 mg/dl 42-12 mg/dl

SERUM CREATININE 17-01-2025 05:54:PM 0.8 mg/dl 1.1-0.6 mg/dl

SERUM ELECTROLYTES (Na, K, C l) 17-01-2025 05:54:PMSODIUM 136 mmol/L 145-136

mmol/LPOTASSIUM 3.8 mmol/L 5.1-3.5 mmol/LCHLORIDE 99 mmol/L 98-107 mmol/L 24 Hours Urinary Sodium ON 18/1/25 - 220 mmol/day 24 Hr URINE VOLUME : 1,700 ml

24 HOURS URINE PROTEIN ON 18/1/25- 250 mg/day. 24 HOURS URINE CREATININE-1.4 g/day RATIO 0.17URINE VOLUME 1,700 ml

24 Hr URINARYPOTASSIUM ON 18/1/25 - 45.0 mmol/day URINE VOLUME 1700 ml USG DONE ON 17/1/25

IMPRESSION:

LONG SEGMENT CIRCUMFERENTIAL WALL THICKENING OF LARGE BOWEL RIGHT ADNEXAL CYST? RIGHT OVARIAN CYST [REVIEW IN FULL BLADDER] REVIEW USG DONE ON 18/1/25

IMPRESSION:

DIFFUSE BOWEL WALL THICKENING NOTED IN ASCENDING, TRANSVERSE AND DESCENDING COLON WITH A MAXIMUM THICKNESS OF 12-13MM

MODERATE ASCITIS

B/L RAISED ECHOGENICITY OF KIDNEYS

REST OF THE FINDINGS CONSISTENT WITH THE PREVIOUS SCAN.

Treatment Given(Enter only Generic Name)

1. INJ PAN 40 MG IV /OD

 

2. INJ ZOFER 4 MG IV/ BD

3. INJ LASIX 40 MG IV/ BD

4. INJ. BUSCOPAN IV/SOS

5. TAB. TELMA 20 MG PO/OD/ 8 AM

6. TAB. ZYTANIX 2.5 MG PO/OD 2PM

7. SYP. MUCAINE GEL 10 ML PO/TID

8. 1 ORS SATCHET IN 1 GLASS OF WATER, DRINK 200 ML

9. OINT.THROMBOPHOBE L/A TID

10. MONITOR VITALS AND INFORM SOS

Advice at Discharge

1. TAB. PREDNISOLONE 5 MG PO/OD TO CONTINUE

2. TAB.AZATHIOPRINE 50 MG PO/OD TO CONTINUE

3. TAB. DYTOR 20 MG PO/OD TO CONTINUE

4. TAB.ZYTANIX 2.5 MG PO/OD TO CONTINUE

5. TAB.TELMA 20 MG PO/OD TO CONTINUE

6. TAB.PAN 40 MG PO/OD X 15 DAYS

7. TAB.ZOFER 4 MG PO/SOS

8. SYP. MUCAINE GEL 10 ML PO/TID X 15 DAYS

9. OINT.THROMBOPHOBE L/A TID

Follow Up

REVIEW SOS

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: 20/1/25

Ward: FEMALE MEDICINE WARD

Unit: V

[21/01/2025, 10:15] Rakesh Biswas: What's the GFR as per this formula?

[21/01/2025, 19:11] Lupus 20F Patient Advocate: Sir akali avuthundi anme tnocha

[21/01/2025, 19:14] Patient Advocate 56F Migraine Hypothyroidism 2000: The patient is hungry, can she eat rice?

[21/01/2025, 21:13] Rakesh Biswas: Yes that's good to hear that she's feeling hungry

And if possible let her take a balanced Harvard plate

[21/01/2025, 21:15] Patient Advocate 56F Migraine Hypothyroidism 2000: Pappulu, pallu,  kuralu anni thinali

[21/01/2025, 21:18] Lupus 20F Patient Advocate: Tnocha anme

[21/01/2025, 21:21] Patient Advocate 56F Migraine Hypothyroidism 2000: Anni thinachu

[21/01/2025, 22:11] Lupus 20F Patient Advocate: Nonveg tnocha

[21/01/2025, 22:12] Rakesh Biswas: Anni thinachu

Aa laga 👇

https://medicinedepartment.blogspot.com/2023/10/healthy-harvard-plate-in-telugu.html?m=1

[25/01/2025, 18:14] Rakesh Biswas: Update?

What medications is she currently on?

What is her current edema like?

[09/02/2025, 08:21] Ajay Reddy 2022 Med PG Kims: Sir the patient got admitted today morning at 6:30 am 

With complains of vomitings 2 episodes at 9 pm food material as content, non bilious

Pain abdomen since 10 pm epigastric and umbilical region non radiating pain, pain is getting relieved on lying in prone position 

Vitals at presentation 

PR: 96/min 

BP:120/70 mmHg

RR:22 cpm 

Spo2:96% on RA

[09/02/2025, 13:42] Rakesh Biswas: Pancreatitis? Steroid or azathioprine induced?

Why did they not share any updates since 21st January?

[09/02/2025, 13:45] Rakesh Biswas: "The number of patients treated with azathioprine to cause an episode of pancreatitis was 36 (induction of remission) and 31 (maintenance of remission).The risk of pancreatitis in patients receiving azathioprine across all contexts was 3.80%, compared with a control risk of 0.2% (placebo) and 0.5% (5-aminosalicylic acid agents)."

Unquote

https://fg.bmj.com/content/12/5/423

[09/02/2025, 13:46] Rakesh Biswas: Azathioprine induced pancreatitis usually runs a benign self limited course with rapid disappearance of signs and symptoms upon with drawl of the drug. 

Unquote

https://www.primescholars.com/articles/azathioprine-induced-pancreatitis-in-a-patient-with-coexisting-autoimmune-pancreatitis-and-hepatitis-97835.html

[09/02/2025, 13:59] Ajay Reddy 2022 Med PG Kims: On per abdominal examination there was tenderness in umbilical region sir 

And the patient was also comfortable on lying in prone position

[09/02/2025, 14:01] Ajay Reddy 2022 Med PG Kims: USG showed this sir

[09/02/2025, 14:06] Rakesh Biswas: Other than inflammatory bowel disease that we had been considering for a few weeks since her first usg few weeks back showed this bowel thickening, the other important pathology to rule out is tuberculosis. @⁨Zain Alam KIMS Pg⁩ do they do free colonoscopy there in Gandhi medical college as this patient is not affordable? 

Also Ajay can you share the previous latest chest X-rays and sputum AFB and CBNAAT?

[09/02/2025, 14:09] Rakesh Biswas: Pain relieved by prone position was our initial cue to suspect pancreatitis

[09/02/2025, 14:09] Rakesh Biswas: Looks clear

[09/02/2025, 14:22] Ajay Reddy 2022 Med PG Kims: Epigastric and umbilical region pain with tenderness in umbilical region along with relief of pain on lying llin prone position or lateral position made me think pancreatitis and she also told if she drinks or eats food abdominal pain is increasing itseems sir

[09/02/2025, 14:25] Rakesh Biswas: Yes you were on the right track before the ultrasound findings added another layer of complexity

[09/02/2025, 18:03] pajr.in CEO, NHS Endocrinologist: Are we temporarily withdrawing the drug then?

[09/02/2025, 19:08] Rakesh Biswas: Yes let's keep it on hold till the uncertainty is resolved @⁨Ajay Reddy 2022 Med PG Kims⁩

[09/02/2025, 19:40] Ajay Reddy 2022 Med PG Kims: Okay sir

[10/02/2025, 14:39] Rakesh Biswas: Update:

Yesterday's history and ongoing meds reviewed

[10/02/2025, 14:45] Rakesh Biswas: Additional Methyl Prednisolone 500 mg iv od planned by @⁨Dr Ramji SR Medicine⁩ today

Let's review the current status of her proteinuria with a 24 hour urine protein and creatinine.

The spot protein creatinine attached here if reliable doesn't suggest an active lupus nephritis

[10/02/2025, 14:46] Rakesh Biswas: The inflammatory bowel issue needs further investigation with a colonoscopy to rule out tuberculosis.

Let's hold the iv methyl prednisolone till then

[10/02/2025, 14:50] Rakesh Biswas: The urine output is not being monitored since admission! This is supposed to be from 9:00AM yesterday to 9:00AM today! But the patient says she voided most of it outside! @⁨Ajay Reddy 2022 Med PG Kims⁩ @⁨Harika CKD Anemia 2022 Project PI⁩

[10/02/2025, 14:51] Dr Ramji SR Medicine: Sir diagnosis is clear sir..

It's mesenteric vasculitis, which is suggested by her acute presentation, favored by USG abdomen findings,delay In management can lead to complications like perforation sir...

CT abdomen is more appropriate investigation here if there is any doubt in the diagnosis sir

[10/02/2025, 14:51] Rakesh Biswas: You mean CT angiography?

[10/02/2025, 14:52] Rakesh Biswas: Get a CT angiography academic free if you suspect mesenteric vasculitis although a negative result will still not rule out micro vasculopathy

[10/02/2025, 14:53] Dr Ramji SR Medicine: No sir, CT abdomen to look for signs of vasculitis..

CT angio is not giving us much information since the vessels involved are small vessels...

[10/02/2025, 14:54] Rakesh Biswas: What signs do we expect in CT abdomen?

Can we get an Abdominal x-ray to look for any signs of intestinal obstruction?

Currently she doesn't appear to have any signs of intestinal obstruction

[10/02/2025, 14:56] Dr Ramji SR Medicine: Vessels prominence, dilated bowel loops, palisade pattern, ascites,bowel wall thickening, double halo sign

[10/02/2025, 14:57] Rakesh Biswas: Bowel thickening present in ultrasound since last two months

Ascites absent

What is the sensitivity of others?

Can one rule out intestinal vasculitis if the CT abdomen is normal?

[10/02/2025, 14:58] Rakesh Biswas: @⁨Harika CKD Anemia 2022 Project PI⁩ please get an AxR abdomen ap view ASAP

[10/02/2025, 14:58] Dr Ramji SR Medicine: Minimal inter bowel fluid is present sir...

[10/02/2025, 15:00] Rakesh Biswas: @⁨Harika CKD Anemia 2022 Project PI⁩ get a surgery opinion ASAP. Wasn't taken by @⁨Ajay Reddy 2022 Med PG Kims⁩ yesterday?

[10/02/2025, 15:09] Dr Ramji SR Medicine: Ko SF, Lee TY, Cheng TT, et al.: CT findings at lupus mesenteric vasculitis, Acta Radiol 38:115–120, 1997.

[10/02/2025, 15:10] Dr Ramji SR Medicine: Article is not available for free sir, the question to sensitivity may be found in this article sir..

[10/02/2025, 15:12] Dr Ramji SR Medicine: Yesterday we managed her symptoms, while thinking of possible etiologies sir....

[10/02/2025, 15:38] Harika CKD Anemia 2022 Project PI: Okay sir

[10/02/2025, 16:01] Rakesh Biswas: Lets establish that she has intestinal obstruction with an abdominal x-ray and take the surgeons into the loop. 

Let's see if a CT abdomen can be done academic free

[10/02/2025, 19:08] Rakesh Biswas: Thanks. Please get this reported by the radiology.

Please share the surgery notes

The abdominal x-ray doesn't look normal

[10/02/2025, 19:09] Harika CKD Anemia 2022 Project PI: Okay sir

The pg said she would look the case now and then will update sir

[10/02/2025, 19:50] Rakesh Biswas: Evening update:

Progressive azotemia, oliguria since morning

Urea -49 to 87

Creat -1.1 to 2.7

[10/02/2025, 20:10] Dr Ramji SR Medicine: She had significant volume loss since the onset of illness, moreover any oral correction is not tolerated by the patient sir..

Iv volume replacement was inadequate which I have asked to do strictly...

Unless her primary cause is  treated, this volume loss in the form of vomiting may continue..

This is my approach towards this case sir as of now...

[10/02/2025, 20:37] Rakesh Biswas: Agree.

Can check ivc movement in inspiration and expiration using pocus ASAP @⁨Harika CKD Anemia 2022 Project PI⁩

[10/02/2025, 20:38] Rakesh Biswas: What is the primary cause? Unless we do a colonoscopy or CT abdomen that remains uncertain. Any luck with getting it academic free?

[10/02/2025, 20:55] Dr Ramji SR Medicine: SLE with GI vasculitis (presenting complaint)

[10/02/2025, 21:28] Pushed Communicator 1N22: Sir its looking like colon cut off sign ?

[10/02/2025, 23:55] pajr.in CEO, NHS Endocrinologist: An early Rigler sign perhaps can help?

[11/02/2025, 07:17] Rakesh Biswas: Partially.

Can't see a distinct cut off

[11/02/2025, 07:18] Rakesh Biswas: What features of the patient suggest gi vasculitis other than the fact that it's one of the differentials explaining her features of intestinal obstruction?

[11/02/2025, 08:36] Dr Ramji SR Medicine: She doesn't have substrate to suspect GI obstruction sir, pseudo obstruction is better differential

She doesn't have colicky pain, abdominal distension

Moreover already USG abdomen is done it features are suggestive of vasculitis, with involvement in 2 different sites, small bowel and large bowel..

[11/02/2025, 08:38] Dr Ramji SR Medicine: All her features are better fitting to vasculitis than obstruction sir..

[11/02/2025, 08:50] Rakesh Biswas: What usg features in her suggest vasculitis?

[11/02/2025, 08:54] Dr Ramji SR Medicine: Wall thickening, mild fluid..

[11/02/2025, 09:56] Rakesh Biswas: That can be due to any cause of inflammatory bowel

I'm writing to the MS and director in the staff group for help regarding her CT and colonoscopy

[11/02/2025, 13:28] pajr.in CEO, NHS Endocrinologist: Does she have a lupus flare now? Is Vasculitis an indication for high dose Methylpred?

I recall we do Pred 1mg/kg here

[11/02/2025, 13:35] Dr Ramji SR Medicine: It is sir..

[11/02/2025, 13:36] pajr.in CEO, NHS Endocrinologist: Alright. 👍🏼

Any literature if possible?

[11/02/2025, 14:40] Rakesh Biswas: Afternoon update and timeline by @⁨Harika CKD Anemia 2022 Project PI⁩ 

In bed

On iv NS 50 ml/hour and since morning received only 300 ml! Too less? @⁨Harika CKD Anemia 2022 Project PI⁩ 

Passed 100 ml just now!

Need

[11/02/2025, 14:43] Rakesh Biswas: The ml graduations are well visible! Simple and nice container for measuring volume from a discarded NS bottle

[11/02/2025, 14:43] Rakesh Biswas: Passed some loose stools right now

[11/02/2025, 14:47] Rakesh Biswas: Rising creatinine trends

[11/02/2025, 14:51] Rakesh Biswas: @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ do you know anyone there in LB Nagar who can help us with the Gastro colonoscopy there?

[11/02/2025, 14:52] Tushara Reddy KIMS 2023: No one is answering the call sir i will try again later sir

[11/02/2025, 14:57] Sai Charan Kulkarni 2020 KIMS Pg: One of my batchmate in KHL is now Gastro resident in NIMS sir. Will try him

[11/02/2025, 14:59] Rakesh Biswas: Conversations with NIMs gastro resident and our ex UG PG:

[11/02, 13:12] : Can you help a 20F with intestinal obstruction with inflammatory bowel and AKI in the background of Lupus if we send her to you there just for the colonoscopy biopsy and back?

Off course if you want to admit her and go full length that also is great.

Her case report is here👇

https://pajrcasereporter.blogspot.com/2024/12/20f-lupus-nephritis-relapse-2-weeks.html?m=1

[11/02, 13:22] NIMS Gastro Kims UG PG: Is she having intestinal obstruction right now sir ?

[11/02, 13:32] NIMS Gastro Kims UG PG: Sir please ask the patient to come to nims tomorrow to meet sir. I’ll give them appointment for colonoscopy on a later date . Our schedule is full for this week already .

[11/02, 14:53]: Yes since the last few days also with AKI oliguria 

Just now she feels slightly better

[11/02, 14:55]: Tomorrow in your OPD? Is it only on Wednesday?

Another 20M we had discussed with you for hypersplenism and possible portal hypertension earlier went to NIMs but couldn't meet you. Not sure which day it was

[11/02/2025, 15:03] Rakesh Biswas: I meant the conversation below from 18/1/25 but now realise we didn't actually have to administer high dose dexa then as the crisis subsided and she was discharged and forgotten without further probe with a colonoscopy.

To quote from the case report link shared above:

"PPM 2 - Are any alternatives being considered?

Does she need a pulse dosing again?

PPM 1 - This time she also appears to have an imaging finding of inflammatory bowel dose in her colon since last admission which appears to be persistent and they can't afford a colonoscopy.

Yes likely. Although iv dexa will be less taxing perhaps.

PPM 2 - I understand the imperative for this although aren't the best outcomes seen with the reliable Methylpred?

I understand each vial costs north of 1k.

PPM 1 - That's a lot.

PPM 2 - To save a kidney?

And consequently human capital?

PPM 1 - Are their studies that dexamethasone can't?

Let's try seeing if there are studies to support that imperative.

PPM 2 - Will let the treating team share.

PPM 1 - 😂

PPM 2 - No quality or reliable data comparing Dexa vs MP. May have to take some expert opinions I guess.

PPM 1 - 👍Which expert worth his salt would be spending time working in low resource settings treating lupus nephritis with dexa instead of MP?

We do have one such non expert generalist's notes documented possibly in tabula rasa. Will try to search and share.

PPM 2 - PPM 1."

[11/02/2025, 15:03] Rakesh Biswas: I guess I'll have to search my previous Lupus dexa records now

[11/02/2025, 15:18] Rakesh Biswas: 👆Found this but the original udhc.co.in disappeared before we switched to blogspot and I can't access the dexa dose details! She didn't have a bad outcome from what I can recall.

[11/02/2025, 15:22] Rakesh Biswas: 👆Finally located the dexa dose we had used!

[11/02/2025, 15:34] Rakesh Biswas: 10 years back similar Lupus patient case report with extensive engagement in tabula rasa (similar to CBBLE PaJR) 👇

https://globaludhc07.blogspot.com/2016/02/a-26-years-old-woman-with.html?m=1

[11/02/2025, 15:41] Rakesh Biswas: Can talk to NIMs Gastro and our ex UG PG.

[11/02/2025, 15:47] Rakesh Biswas: [11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir. And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable .

[11/02, 15:46] : Our PGs will text you to coordinate

[11/02/2025, 18:47] Patient Advocate 56F Migraine Hypothyroidism 2000: Can these be added in the case report?

[11/02/2025, 19:01] Rakesh Biswas: Yes that would be great if it can be done

[11/02/2025, 20:19] Patient Advocate 56F Migraine Hypothyroidism 2000: Please check the case report if everything is fine.

[11/02/2025, 20:27] Rakesh Biswas: Thanks. Yes this looks very good

[12/02/2025, 13:49] Rakesh Biswas: Given at what time?

Yesterday evening? 

There was nothing mentioned in the file about it when I evaluated her in the afternoon and she had already recovered by afternoon as per my findings

[12/02/2025, 14:49] Rakesh Biswas: Saw this note now! So even when i was evaluating her at this time yesterday the iv 500mg methyl prednisolone was started by Nithin ICU PG at 3:00PM and I wasn't even informed by Nithin about it although both of us were seeing the patient together!

[12/02/2025, 15:03] Rakesh Biswas: @⁨Nithin Chakravarthy Kims 2023 PG⁩ discarded 500 mg in that vial after giving 500 mg from the 1000mg vial

Nithin thinks as per his observations as ICU pg it's the forced ryles tube insertion followed by removal after 2-3 hours which made her recover.

@⁨Harika CKD Anemia 2022 Project PI⁩ and @⁨Pushed Communicator 1N22⁩ think it could have been a pancreatitis which has recovered spontaneously and coincidentally patient also received iv methyl pred at 3:00 PM by which time she had recovered even before the methylprednisolone.

I feel while I can agree with their hypothesis, it's still possible that her supposed intestinal vasculitis was recovering slowly and yesterday's iv methylprednisolone may have helped. Again not sure how to resolve this uncertainty except to await the macroscopic colonoscopic findings and microscopic histopathology of the intestine to check what was really going on there by sending her to NIMs and hoping for the best

[12/02/2025, 15:07] Rakesh Biswas: @⁨Harika CKD Anemia 2022 Project PI⁩ let's send her to NIMs on Friday👇

[11/02, 15:05] NIMS Gastro Kims UG PG: This week my Opd is on Wednesday and Friday sir. 

And for next two weeks my Opd is on Tuesday , Thursday and Saturday. They can come on any of these days when she is stable .

[11/02, 15:46] : Our PGs will text you to coordinate

[13/02/2025, 09:10] Harika CKD Anemia 2022 Project PI: Subjectively -patient feels better compared to yesterday

But yesterday after food intake - had abdominal pain which subsided with buscopan.

No vomitings

Passed stools yesterday afternoon.

Aki in resolving trends 

Urea - 110---92

Creat -2.3 ---1.4

I/o - 2900ml/650ml

For the first time yesterday night bp-150/90mm hg

And since then bp recordings -are 160/100mmhg

[13/02/2025, 09:16] Rakesh Biswas: Thanks

3 doses of methyl prednisolone over?

[13/02/2025, 09:16] Harika CKD Anemia 2022 Project PI: Today is the last dose sir

[13/02/2025, 09:16] Rakesh Biswas: What about her 24 hour protein and creatinine?

[13/02/2025, 09:31] Rakesh Biswas: Even the Lupus patient in the opposite bed had the same value?!!

[13/02/2025, 09:33] Harika CKD Anemia 2022 Project PI: Yes sir almost similar

[13/02/2025, 09:34] Rakesh Biswas: If this is true then this is the closest she has come to remission!

Now how much of that was due to her azathioprine (for which pancreatitis was one of the current differentials for her abdominal pain) and how much is due to one dose of methyl prednisolone is a big head scratcher! @⁨pajr.in CEO, NHS Endocrinologist⁩ ?

[13/02/2025, 11:31] Rakesh Biswas: So one thing is clear after reading this that when we think of intestinal vasculitis in Lupus it needs to be before the vessels enter the intestine. In that case its difficult to explain her ultrasound findings of bowel thickening.

Also to prove Lupus intestinal vasculitis truly one may actually require laparoscopic biopsy of the affected vessels before they enter the intestine in the mesentery which in this particular patient will be very difficult to say the least.

However a colonoscopy to chase the USG bowel thickening is still worthwhile and if there's really a lesion there then a biopsy could tell a lot provided we a good coordination between endoscopist and pathologist

[13/02/2025, 14:44] Rakesh Biswas: I talked to the father who wants to go to NIMs next week on Tuesday, Thursday or Saturday.

@⁨Harika CKD Anemia 2022 Project PI⁩ can you also get a rough estimate of the potential costs from Srujan

[13/02/2025, 15:05] Harika CKD Anemia 2022 Project PI: Yes sir I spoke with sir

He said that he will be available on Tuesday Thursday and Saturday

Since they will be discharged tomorrow

I think they can go on Tuesday sir  to have an appointment for the later date 

And colonoscopy would cost around 2.5k 

With biopsy -rs.700 sir

Approx 3.4-4k would be an estimate sir

[14/02/2025, 15:14] Rakesh Biswas: @⁨Dr Ramji SR Medicine⁩ as a cyclic iv pulse cyclophosphamide is being planned for her under your guidance, it would be great if you can share any good RCT that shows efficacy of that regime vs other care 

@⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ would be nice if you too could share

[14/02/2025, 15:49] Rakesh Biswas: Her BP spikes are an effect of iv methyl prednisolone or lupus nephritis?

[14/02/2025, 16:17] Dr Ramji SR Medicine: I'm unavailable today for discussion sir...

[14/02/2025, 19:54] Tushara Reddy KIMS 2023: The abdomen is distended now sir visually 

Yesterday the abdominal girth is 69 cms 

Today eve it is 73 cms sir 

She did not pass stools today

[14/02/2025, 21:43] Rakesh Biswas: Thanks.

Let's hope we get her colonoscopy quickly before she again goes into another obstruction

[15/02/2025, 14:34] Dr Ramji SR Medicine: Our patient is having loose stools due to laxative sir, she is not feeling well, so instructed our PG's to postpone plan for discharge and counseled the attenders too about the same sir..

Goal is make her fit for colonoscopy guided biopsy on Tuesday.. @⁨Rakesh Biswas⁩...

[19/02/2025, 18:38] Lupus 20F Patient Advocate: Gd evng sir nd madam tblts  m chepaldu gaa

[19/02/2025, 19:11] Rakesh Biswas: Please share the tablets your patient is currently taking. Her colonoscopy is planned on Friday.

Please ask her to continue the tablets she was previously taking till we get her colonoscopy report

[19/02/2025, 19:12] Rakesh Biswas: @⁨pajr.in CEO, NHS Endocrinologist⁩ Srujan texted. He'll also try to get her colonoscopy bill waived. They may have to pay for the pathology bill. I guess that would be great.

[19/02/2025, 20:19] Harika CKD Anemia 2022 Project PI: Yes sir they visited and they are scheduled on Friday for colonoscopy

They have doubt regards what medications to continue and have cleared them sir

[21/02/2025, 16:17] Rakesh Biswas: Update:

The colonoscopy mucosa appeared normal?

Could it have been an intestinal vasculitic flare up that gave rise to her intestinal obstruction symptoms then?

[21/02/2025, 16:18] Harika CKD Anemia 2022 Project PI: Vasculitic flare up only supports it i think so sir

[21/02/2025, 16:20] Rakesh Biswas: Yes! @⁨Dr Ramji SR Medicine⁩ 

[21/02, 16:18]  NIMS Gastro Kims UG PG: The mucosa upto the terminal ileum was normal sir . Vasculitic flare is one possibility and the other may be small bowel strictures which cause intermittent obstruction too . As she is asymptomatic now , it would be better to get a cect enterography the next time she gets any features if obstruction . We did take biopsy just in case

[21/02/2025, 17:52] Dr Ramji SR Medicine: Acute on Chronic vasculitis with strictures causing pseudo obstruction sir...

[24/02/2025, 09:49] Ajay Reddy 2022 Med PG Kims: Patient admitted  today morning with complains of vomitings since 4 am 4-5 episodes 

1 st episode was some of the food contents and watery .

Next episodes patient complains of hematemesis - dark colored 

No complains of pain abdomen, constipation, fever 

Vitals on presentation 

Pr : 92/min 

BP: 110/70 mmHg 

Spo2: 95 on RA 

Rr:22 cpm 

P/A : soft, non tender

[24/02/2025, 09:51] Dr Ramji SR Medicine: Have they taken any photo of haematemesis??

[24/02/2025, 09:52] Dr Ramji SR Medicine: How sure you are it's haematemesis??

[24/02/2025, 09:56] Rakesh Biswas: Any maintenance prednisolone she was on at discharge?

[24/02/2025, 14:28] Ajay Reddy 2022 Med PG Kims: Yes sir 

She is on prednisolone 10 mg po od, tab. Azathioprine 50 mg po od

[24/02/2025, 19:34] Rakesh Biswas: I checked in the afternoon. Although we had written 10 they were taking 5 but I guess that's okay and may not be responsible for hypoadrenalism causing her current symptoms.

Drug induced gastritis is the other possibility for which we shall get her upper GI endoscopy tomorrow

[25/02/2025, 10:56] Rakesh Biswas: Update:

BP charting since 4:00PM revealed higher spikes 140/100 to 150/100 and night 7:30 PM took Telma 40 and hourly BP monitoring slightly relented although today it's again higher before her planned upper GI endoscopy. @⁨Ajay Reddy 2022 Med PG Kims⁩ we'll also need to review her 24 hour urinary protein and creatinine which for the first time had shown near remission of her lupus nephritis during last admission

[26/02/2025, 22:18] Rakesh Biswas: Current problem:

Persistent vomiting immediately after food

Invite inputs @⁨pajr.in CEO, NHS Endocrinologist⁩ @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ @⁨Dr Ramji SR Medicine⁩

[26/02/2025, 22:20] Dr Ramji SR Medicine: I shall give my inputs tomorrow sir after talking to the patient..

[26/02/2025, 22:46] Sai Charan Kulkarni 2020 KIMS Pg: Given her complaints : 

22F immunosuppressive with acute to sub acute abdominal pain and vomitings with Flare up of Lupus nephritis. With background of endocarditis 

*assuming Normal UGIE attached above 

Localisation - 

GI - 

1. Mesentric ischemia / intestinal angina

2. ⁠Lupus enteritis / Vasculitis ( sub acute ) - associated with flare up of LN

2. ⁠ IBD 

3. ⁠ischemic colitis ( ?mesentric vessels occlusion again )

? External compression of bowel or blood vessel

Renal - azotemia / ?middle molecules triggering CTZ

CNS- raised ICP ( less likely ) 

@⁨Ajay Reddy 2022 Med PG Kims⁩  did we do her CT angio..? Or CECT abd..?

[26/02/2025, 22:49] PI Portal Hypertension Project 2022: Cect abd or CT angio was not done sir

[26/02/2025, 22:50] pajr.in CEO, NHS Endocrinologist: How would they help?

[26/02/2025, 22:50] pajr.in CEO, NHS Endocrinologist: Why not drug induced? Vomiting immediately after eating?

[26/02/2025, 22:52] Sai Charan Kulkarni 2020 KIMS Pg: Yes sir possible. She is been on AZA which could cause pancreatitis too.

[26/02/2025, 22:52] PI Portal Hypertension Project 2022: https://pmc.ncbi.nlm.nih.gov/articles/PMC8214088/

[26/02/2025, 22:53] pajr.in CEO, NHS Endocrinologist: Yeah. So maybe Lipase with a USG should suffice for now?

[26/02/2025, 22:53] pajr.in CEO, NHS Endocrinologist: Relevant bits please.

[26/02/2025, 22:53] PI Portal Hypertension Project 2022: One of our faculty was thinking it could be cyclic vomiting syndrome as a differential sir

[26/02/2025, 22:54] pajr.in CEO, NHS Endocrinologist: Isn't that a diagnosis of exclusion and is usually not sinister as seen here?

[26/02/2025, 22:55] Sai Charan Kulkarni 2020 KIMS Pg: Rather colonoscopy would be better. 

Look for any signs of bowel inflammation or ischemia or an ulcers and take a bit for histopathology.

[26/02/2025, 22:56] pajr.in CEO, NHS Endocrinologist: Vomiting immediately after food intake would localise the problem much higher wouldn't it? Which means the problem is involving the digestive machinery - esophagus, stomach, hepato-pancreatico-biliary organs?

[26/02/2025, 22:59] pajr.in CEO, NHS Endocrinologist: I wish I had WhatsApp AI but can you please ask what is the incidence of vomiting in patients taking Azathioprine?

[26/02/2025, 22:59] Sai Charan Kulkarni 2020 KIMS Pg: @⁨Meta AI⁩  incidence of vomitings in patients in chronic azathioprine

[26/02/2025, 22:59] Meta AI: Azathioprine is an immunosuppressive medication commonly used to treat autoimmune diseases, prevent organ rejection in transplant patients, and manage certain inflammatory conditions.

Regarding the incidence of vomiting in patients taking chronic azathioprine, here are some findings:

- A study published in the Journal of Clinical Pharmacology found that gastrointestinal symptoms, including nausea and vomiting, occurred in approximately 12% of patients taking azathioprine (1).

- Another study published in the British Journal of Clinical Pharmacology reported that vomiting was experienced by around 5% of patients receiving azathioprine (2).

- A review of azathioprine's safety profile published in the journal Expert Opinion on Drug Safety noted that gastrointestinal adverse effects, including vomiting, are relatively common, affecting up to 20% of patients (3).

Please note that the incidence of vomiting can vary depending on factors such as:

- Dosage: Higher doses may increase the risk of gastrointestinal side effects.

- Individual tolerance: Some patients may be more susceptible to azathioprine's side effects.

- Concomitant medications: Taking other medications that can cause gastrointestinal upset may increase the risk of vomiting.

If you're experiencing persistent or severe vomiting while taking azathioprine, it's essential to consult your healthcare provider for proper evaluation and guidance.

References:

1. Journal of Clinical Pharmacology, "Azathioprine-induced gastrointestinal symptoms: a review of the literature" (2018)

2. British Journal of Clinical Pharmacology, "Adverse effects of azathioprine in patients with inflammatory bowel disease" (2015)

3. Expert Opinion on Drug Safety, "Azathioprine: a review of its safety profile" (2019)

I hope this helps! If you have further questions or concerns, feel free to ask.

[26/02/2025, 23:00] pajr.in CEO, NHS Endocrinologist: Please ask absolute numbers and duration of Azathioprine in study 1

[26/02/2025, 23:03] PI Portal Hypertension Project 2022: @⁨Meta AI⁩ absolute numbers and duration of Azathioprine in study 1

[26/02/2025, 23:03] Meta AI: In Study 1, the absolute numbers and duration of Azathioprine were as follows:

- *Number of patients*: 40 children with inflammatory bowel disease (IBD) ¹

- *Duration of Azathioprine treatment*: The study doesn't explicitly state the duration, but it mentions that thiopurines can take up to 14 weeks to be fully effective ¹

- *Azathioprine dose*: The mean azathioprine dose was 1.3±0.4 mg/kg ¹

- *Thiopurine metabolite measurement timing*: Blood tests were performed 6 weeks after the initiation of therapy ¹

[26/02/2025, 23:10] Sai Charan Kulkarni 2020 KIMS Pg: @⁨pajr.in CEO, NHS Endocrinologist⁩ @⁨PI Portal Hypertension Project 2022⁩

Incidence of Vomiting in Chronic Azathioprine Use: A Comprehensive Analysis of Large-Scale Medical Studies  

Azathioprine, a widely used immunosuppressive agent, has demonstrated clinical efficacy across various autoimmune and inflammatory conditions. However, its therapeutic benefits are often accompanied by gastrointestinal adverse effects, with vomiting representing a clinically significant concern. This report synthesizes data from multiple large-scale studies to quantify the incidence of vomiting during chronic azathioprine therapy, providing granular insights into population-specific risks, dose dependencies, and management strategies.  

---

## Epidemiological Overview of Azathioprine-Associated Vomiting  

The incidence of vomiting during azathioprine therapy varies substantially across patient populations and treatment protocols. A landmark study involving **622 inflammatory bowel disease (IBD) patients** revealed that **68 patients (10.9%)** discontinued treatment due to nausea and vomiting, with symptoms typically emerging within a mean of **106 days** after initiation[6]. Notably, this cohort received a mean dose of **1.77 mg/kg/day**, though no direct correlation between dose intensity and emetic frequency was observed[6]. These findings align with a Korean pediatric IBD study where **27 of 174 patients (15.5%)** experienced vomiting at a mean dose of **1.38 mg/kg/day**, with **10 patients (5.7% of total cohort)** requiring permanent discontinuation[3][5].  

---

## Dose-Response Relationships and Temporal Patterns  

Contrary to conventional pharmacokinetic expectations, vomiting incidence does not exhibit strong dose dependency. In the Korean pediatric cohort, vomiting occurred across a broad dose range (**1.38 ± 0.46 mg/kg/day**), with symptom onset delayed until a mean of **10.4 months** into therapy[3]. This contrasts with adult populations where emetic episodes frequently manifest earlier, suggesting age-related differences in drug tolerance. A paradoxical observation emerged from a 14-patient gastritis study, where only **1 patient (7.1%)** developed dose-limiting nausea/vomiting despite prolonged azathioprine exposure (>2.5 months)[2], highlighting condition-specific variability in adverse effect profiles.  

---

## Population-Specific Risk Stratification  

### Pediatric vs. Adult Populations  

Pediatric patients demonstrate heightened vulnerability, with **15.5% vomiting incidence** in Korean children[3] versus **10.9%** in mixed-age IBD cohorts[6]. This disparity may reflect developmental differences in thiopurine methyltransferase (TPMT) activity or enterohepatic recirculation patterns. Notably, pediatric data showed **37% of vomiting cases** required dose reduction, while adults predominantly required complete cessation[3][6].  

### Disease-State Modifiers  

IBD patients exhibit higher emetic rates (**10.9-15.5%**[3][6]) compared to transplant recipients (<1%[4]). This discrepancy likely stems from baseline gastrointestinal inflammation in IBD exacerbating drug-induced mucosal irritation. A critical finding from the 622-patient IBD study revealed **64% remission rates** in Crohn's disease patients persisting beyond six months of therapy despite vomiting incidence[6], underscoring the risk-benefit calculus in chronic management.  

---

## Management Algorithms and Clinical Outcomes  

### Pharmacological Interventions  

Proactive antiemetic use remains controversial due to potential drug interactions. The NHS guidelines recommend dietary modifications (e.g., administration with meals) as first-line management, reporting symptom resolution within one week for most patients[1]. Refractory cases often necessitate dose reduction, successful in **29.6% of pediatric patients**[3], though this risks subtherapeutic immunosuppression.  

### Discontinuation Thresholds  

Permanent cessation rates vary by indication:  

- **5.7%** in pediatric IBD[3]  

- **10.9%** in adult IBD[6]  

- **7.1%** in chronic gastritis[2]  

Notably, **17% of adult IBD patients** restarting azathioprine after initial intolerance achieved long-term tolerance through gradual dose escalation[6], suggesting protocolized rechallenge strategies may mitigate attrition.  

---

## Mechanistic Considerations in Emetogenesis  

The dual-phase vomiting pathophysiology involves:  

1. **Direct mucosal irritation** via 6-thioguanine nucleotide accumulation in gut epithelium[4]  

2. **Central chemoreceptor activation** through proinflammatory cytokine cross-talk (IL-6, TNF-α)[3]  

Hepatic metabolism polymorphisms further modulate risk, with slow TPMT metabolizers showing **3.2-fold increased emetic propensity** in pharmacogenetic subanalyses[6]. These insights inform emerging genotype-guided dosing protocols aiming to balance efficacy and tolerability.  

---

## Longitudinal Safety Data  

The 622-patient cohort provided critical temporal insights:  

- **42.3% of vomiting cases** occurred within 3 months  

- **28.1%** manifested between 3-12 months  

- **29.6%** emerged after >1 year of therapy[6]  

This prolonged risk window contradicts traditional "early toxicity" paradigms, necessitating ongoing monitoring even in long-term users. Late-onset cases correlated with cumulative dose thresholds exceeding **200g**, suggesting mitochondrial toxicity mechanisms[4].  

---

## Comparative Safety Profiles  

While vomiting represents a predominant gastrointestinal effect, its incidence eclipses other azathioprine toxicities:  

- **4.6% leukopenia**[6]  

- **7.5% pancreatitis**[3]  

- **2.9% hepatotoxicity**[3]  

Notably, **68% of drug discontinuations** stem from vomiting/nausea compared to **4.6% for hematologic effects**[6], emphasizing its clinical impact on treatment adherence.  

---

## Conclusion: Risk Mitigation in Clinical Practice  

Synthesizing data from 796 patients across three continents, chronic azathioprine therapy carries a **11-15% vomiting risk**, with absolute case numbers ranging from **68/622**[6] to **27/174**[3] in large cohorts. Proactive genotype screening (TPMT, NUDT15), staggered dosing protocols, and early antiemetic support may reduce attrition. Future research should prioritize randomized trials of aprepitant and olanzapine as prophylactic agents in high-risk populations.

Sources

[1] Side effects of azathioprine - NHS https://www.nhs.uk/medicines/azathioprine/side-effects-of-azathioprine/

[2] The effect of azathioprine on gastric mucosal histology and acid ... https://pubmed.ncbi.nlm.nih.gov/4696531/

[3] Adverse Events Associated with Azathioprine Treatment in Korean ... https://pmc.ncbi.nlm.nih.gov/articles/PMC3819691/

[4] Azathioprine Side Effects: Common, Severe, Long Term - Drugs.com https://www.drugs.com/sfx/azathioprine-side-effects.html

[5] [PDF] Adverse Events Associated with Azathioprine Treatment in Korean ... https://www.pghn.org/Synapse/Data/PDFData/1121PGHN/pghn-16-171.pdf

[6] The efficacy of azathioprine for the treatment of inflammatory bowel ... https://pmc.ncbi.nlm.nih.gov/articles/PMC1773162/

[7] Long -term safety and toxicity of azathioprine in patients with air ... https://ijdvl.com/long-term-safety-and-toxicity-of-azathioprine-in-patients-with-air-borne-contact-dermatitis/

[8] [PDF] Azathioprine (Imuran) https://www.cuh.hse.ie/media/pil/azathioprine-imuran-gp-sheet-2023.pdf

[9] Effect of azathioprine intolerance on outcomes of inflammatory ... https://pmc.ncbi.nlm.nih.gov/articles/PMC5369706/

[10] Hypersensitivity to azathioprine in a patient with Crohn's disease http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082017001000013

[11] Long‐term safety and effectiveness of azathioprine in the ... https://onlinelibrary.wiley.com/doi/full/10.1002/jgh3.12955

[12] azathioprine oral: Uses, Side Effects, Interactions, Pictures ... - WebMD https://www.webmd.com/drugs/2/drug-13771/azathioprine-oral/details

[13] Azathioprine (Imuran®) Drug Information Sheet https://www.hopkinsarthritis.org/patient-corner/drug-information/azathioprine-imuran/

[14] [PDF] 787fm.3 azathioprine for use in rheumatology, dermatology https://www.bucksformulary.nhs.uk/docs/Guideline_787FM.pdf

[15] Azathioprine (oral route) - Mayo Clinic https://www.mayoclinic.org/drugs-supplements/azathioprine-oral-route/description/drg-20067180

[16] Long-term Efficacy and Safety of Azathioprine in Ulcerative Colitis https://academic.oup.com/ecco-jcc/article/9/2/191/439760

[17] [PDF] updated azathioprine guidelines. - London - Whittington Hospital https://www.whittington.nhs.uk/document.ashx?id=6404

[18] Azathioprine (Imuran®) Uses and Side Effects https://www.chp.edu/our-services/transplant/liver/education/medications/azathioprine-imuran

[19] Weekly azathioprine pulse versus daily azathioprine in the treatment ... https://ijdvl.com/weekly-azathioprine-pulse-versus-daily-azathioprine-in-the-treatment-of-parthenium-dermatitis-a-non-inferiority-randomized-controlled-study/

[20] Azathioprine: Side Effects, Dosage, Uses, and More - Healthline https://www.healthline.com/health/drugs/azathioprine-oral-tablet

[21] Azathioprine - StatPearls - NCBI Bookshelf https://www.ncbi.nlm.nih.gov/books/NBK542190/

[22] Azathioprine: Side Effects & Treatment - Cleveland Clinic https://my.clevelandclinic.org/health/drugs/9407-azathioprine

[23] Azathioprine | Side-effects, uses, time to work - Versus Arthritis https://versusarthritis.org/about-arthritis/treatments/drugs/azathioprine/

[24] Toxicity of azathioprine: why and when? analysis of the prevalence ... https://www.scielo.br/j/ag/a/f9L5FC63GsTFFxvJsZ3TrrN/

[25] Real-World Study Finds Long-Term Azathioprine Treatment Safe ... https://www.managedhealthcareexecutive.com/view/real-world-study-finds-long-term-azathioprine-treatment-safe-effective-in-patients-with-ibd

[26] Long‐term safety and effectiveness of azathioprine in the ... https://pmc.ncbi.nlm.nih.gov/articles/PMC10517446/

[27] Azathioprine in ulcerative colitis: Why, when, how and how long to ... https://analyticalsciencejournals.onlinelibrary.wiley.com/doi/10.1002/ddr.20481

[28] [PDF] Azathioprine for patients within adult services (non-transplant ... https://www.covwarkformulary.nhs.uk/docs/chapter01/SCA102-Azathioprine%20non%20transplant%20indications.pdf

[26/02/2025, 23:18] PI Portal Hypertension Project 2022: According to the above study, azathioprine causes vomiting in 10-15% patients sir

[26/02/2025, 23:29] Ajay Reddy 2022 Med PG Kims: Lipase done during previous admission was normal sir

[26/02/2025, 23:33] PI Portal Hypertension Project 2022: She had similar complaints at that time too sir, Lipase was normal

[27/02/2025, 07:30] Rakesh Biswas: Can't trust meta AI or any LLM unless one can actually read the data in a real journal. LLMs are notorious for confabulating

However having said that I guess we should stop azathioprine for now

Please let me know if urine 24 protein and creatinine was collected yesterday and sent today to determine if her lupus nephritis is now in remission or not at least similar to what we found in her last admission

[27/02/2025, 16:17] Rakesh Biswas: [27/02, 14:35] pg: Can we plan renal biospy for her sir?!

[27/02, 16:15] pm: Yes we discussed that today in the afternoon rounds.

Problem is her Lupus nephritis isn't one of the current pressing problems although because her immunosuppressives are getting a bit irregular due to the side effects, the latest suspect for her vomiting is azathioprine induced pancreatitis, her current 24 hour proteinuria has again increased from insignificant the last time few weeks back from 200 mg to 900 mg today

So it's essentially a tight rope between balancing the side effects of her immunosuppressives vs her lupus nephritis, which is compounded by total loss of follow up due to our inability to communicate with her family till she gets readmitted with a crisis!

Now that we have stopped her azathioprine we have to quickly think of an alternative immunosuppressive adjuvant. The last time we rejected mycofenolate in favour of azathioprine was due to cost consideration and also it can cause diarrhoea but I guess Diarrhoea is preferable to pancreatitis and vomiting!

[27/02/2025, 16:58] Harika CKD Anemia 2022 Project PI: Yesterday -2000/400ml

[27/02/2025, 16:58] Rakesh Biswas: Day before?

[27/02/2025, 16:59] Rakesh Biswas: Today's?

[28/02/2025, 09:20] Tushara Reddy KIMS 2023: 1050/200 ml on 26 th sir

[28/02/2025, 09:20] Tushara Reddy KIMS 2023: Today -1100/250 ml sir

[28/02/2025, 09:27] Rakesh Biswas: You mean yesterday's 24 hour urine output was 250 ml?

Last serum creatinine?

[28/02/2025, 12:27] Harika CKD Anemia 2022 Project PI: Sir till evening there was no output

She is dehydrated  

And after iv fluids- urine output was 250ml sir

Slightly better compared to yesterday

2 episodes of vomitings

Pain abdomen+ 

Tenderness in the epigastric region.

No fever spikes

Has passed stools yesterday

S.creat -1.0

[28/02/2025, 13:14] Rakesh Biswas: Yes let's monitor the urine output hourly and replenish her volume hourly as per our hourly evaluation of her ivc mobility

[28/02/2025, 14:24] Rakesh Biswas: @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩  you recall once at the beginning we had tried to start her on mycofenolate mofetil vs azathioprine and @⁨Deepika Kims Med PG 2021⁩ also reviewed the literature on azathioprine vs mycofenolate efficacy here following which we started her on azathioprine as the efficacies and adverse effects appeared comparable.

We now know that azathioprine has been stopped on suspicion of pancreatitis and we have to start on mycofenolate so @⁨Pushed1Comm22⁩ just looked up the prize differences and while mycofenolate is 70 per tablet, azathioprine is 12/- per tablet

[28/02/2025, 15:55] Sai Charan Kulkarni 2020 KIMS Pg: Yes sir our team collectively decided to start her on AZA due to low cost with similar efficacy.

[28/02/2025, 15:59] Sai Charan Kulkarni 2020 KIMS Pg: Yes sir this is from perplexity, analysed by chain of thought and step by step analysis. Agreed A.I. hallucination can’t be ruled out especially in consolidating large studies. But prompts used will alter the results of reasoning sir.

[01/03/2025, 08:19] Dr Ramji SR Medicine: In summary, the cumulative exposure to CYC that 

results in ovarian failure varies by age. To avoid 

amenorrhea, female patients < 20 years old should 

likely receive < 15 to 20 g of total exposure, patients 

aged 20 to 30 should receive < 15 g of total exposure 

and those > 30 should likely receive < 10 g of total 

exposure. We did not make a recommendation for 

maximum exposure to prevent infertility in patients 

> 40 as this group already has a low baseline fertility 

rate, worsened by disease activity. In males, the 

maximum CYC exposure for patients who still wish to 

conceive is lower at approximately 10 g.

[01/03/2025, 08:23] Dr Ramji SR Medicine: We are just calculating the cost of tablets sir.  Length of hospital stays, recurrent admissions, burden on the family members with these recurrent admissions also should be taken into consideration..

[01/03/2025, 08:25] Rakesh Biswas: Agree! Well said 👏

[01/03/2025, 08:26] Rakesh Biswas: So the harms appear to be worth a try!

Please share the efficacy and let's see if it beats the efficacy and harms of mycofenolate mofetil

[01/03/2025, 08:28] Rakesh Biswas: As a comparison, this patient swallowed 19.5 gms of azathioprine before developing what we currently believe is pancreatitis since few weeks!

[01/03/2025, 08:31] Dr Ramji SR Medicine: Selection of drug principally relies on renal biopsy along with other disease activity parameters sir...

So even if a drug is chosen it is chosen out of presumption only.. Not completely evidence based...

In other words we are starting a new experiment, without proving the previous experiments(recommendations) are trash or not working....

[01/03/2025, 08:34] Dr Ramji SR Medicine: We are repeating lipase today sir...

Specificity of lipase is roughly 99 %...

We have to await for lipase results to say it's pancreatitis...

[01/03/2025, 08:37] Dr Ramji SR Medicine: One thing is very clear sir, she is having disease activity, and requires immunosuppression immediately, then  planned for  renal biopsy for definitive decision making.

[01/03/2025, 08:48] Rakesh Biswas: Specificity may not be as important as sensitivity here in this case who already had demonstrated normal lipase during her previous acute attack during her previous admission!

Sensitivity is more important because if it's negative we will still not be able to rule it out as  it's known to have sensitivity varying from 64-100%

Here's a paper citing the same including the fact that even specificity isn't 100% for pancreatitis as IBD can often have high lipase!

https://www.sciencedirect.com/science/article/pii/S1365182X1531176X

[01/03/2025, 08:51] Rakesh Biswas: Agree that she has disease activity and we have been able to suppress it using drugs in the past unfortunately that we are having to discontinue because of cumulative side effects.

In view of no definitive data toward cyclophosphamide which will also need to be discontinued after a few months, i would prefer starting mycofenolate mofetil albeit expensive

However if there is good evidence of a cyclophosphamide pulse showing complete remission without recurrence it could be worth considering. However we need to see the evidence for it. @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ would you like to try perplexity again for this?

[01/03/2025, 09:13] Dr Ramji SR Medicine: I'm thinking that patient has less probability of pancreatitis sir..

Both sensitivity and specificity are high for lipase..

Helps to both rule out, as well as rule in with almost certainty....

[01/03/2025, 09:18] Rakesh Biswas: Sensitivity can vary from 64-100%

Negative doesn't rule out

[01/03/2025, 09:19] Rakesh Biswas: What is our alternate diagnosis for her symptoms?

[01/03/2025, 09:20] Dr Ramji SR Medicine: Though not meeting the cutoff, I'm convinced that patient is having pancreatitis sir...

Withholding azathioprine is justified sir...

[01/03/2025, 09:21] Dr Ramji SR Medicine: Considering her symptoms examination findings and elevation in enzymes...

[01/03/2025, 09:25] Rakesh Biswas: What was her previous amylase lipase during the last admission managed by @⁨Ajay Reddy 2022 Med PG Kims⁩ where our first clinical impression was pancreatitis but we kind of gave it up once the enzymes didn't support that hypothesis

[01/03/2025, 09:36] Ajay Reddy 2022 Med PG Kims: Previous admission lipase was 24 IU/L sir

[01/03/2025, 09:44] Rakesh Biswas: An important learning point worth exploring further here in a thesis project here would be the variability of enzymatic activity in pancreatitis and how a longitudinal follow up is necessary for diagnosis rather than just a few random values? @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ @⁨pajr.in CEO, NHS Endocrinologist⁩ ?

[01/03/2025, 16:39] Rakesh Biswas: Thanks @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ 

@⁨Dr Ramji SR Medicine⁩ @⁨pajr.in CEO, NHS Endocrinologist⁩ if you go through these inputs from AI in the context of our patient, our patient has already demonstrated achievable remission induction in her last visits with proteinuria touching 200 mg near remission. The issue was with maintenance and while she was lucky with the remission front with steroids and azathioprine she developed pancreatitis and hence we just need to switch into another modality to reinstate remission and maintain it. 

The trouble with cyclophosphamide is the cumulative gonadal toxicity so we can use it to achieve remission to begin with even using oral now and then once we reach the gonadal cumulative limit as well as document remission in the coming three months we can then switch to the expensive mycofenolate mofetil?

[01/03/2025, 20:47] Sai Charan Kulkarni 2020 KIMS Pg: My critical thought is to educate attenders regarding cumulative side effects of cyclophosphamide and expensiveness of MMF for maintainance therapy and efficacies of both. Let them understand the current complexities in therapeutic decision making and let them be part of this process sir.

[03/03/2025, 03:40] pajr.in CEO, NHS Endocrinologist: https://pubmed.ncbi.nlm.nih.gov/9436862/

"In the serum samples collected on days 0-1 after the onset of symptoms, lipase was elevated in 100% and amylase in 95%. A 95% sensitivity/specificity was reached at a lipase cutoff near twofold above normal. The receiver-operating characteristics (ROC) showed similar curves for both enzymes, lipase being slightly superior to amylase. The ROC curves from days 2-3 demonstrated a much lower sensitivity/specificity of both enzymes. Lipase, however, was notably superior to amylase: at a sensitivity of 85% the specificity of lipase (amylase) was 82% (68%). In samples from days 4-5 the accuracy of the enzyme assays was even worse; at a sensitivity of 60% the specificity did not increase above 70%."

[03/03/2025, 08:09] Rakesh Biswas: Beautiful! Just as we suspected!

[23/03/2025, 12:50] Lupus 20F Patient Advocate: Gd afternoon sir and madam ninna iron tblt vesukunna ninna 1time vomtings aenae eroju moham kadupu vampu vchindi

[23/03/2025, 13:41] Patient Advocate 56F Migraine Hypothyroidism 2000: The patient has taken iron tablet yesterday and had vomiting once. Today she has facial swelling and bloating stomach

[23/03/2025, 17:54] Rakesh Biswas: Let her hold the iron tablets for now.

When did she start taking them?

[23/03/2025, 17:55] Sai Charan Kulkarni 2020 KIMS Pg: Since Yesterday sir, told to withhold as of now.

[23/03/2025, 17:56] Rakesh Biswas: Why yesterday!

[23/03/2025, 18:28] Sai Charan Kulkarni 2020 KIMS Pg: Yesterday patient father called me inview of nausea and vomiting after taking iron tablet which was taken yesterday first time after discharge. Reassured and advised to stop iron tablet as of now sir

[06/04/2025, 18:40] Harika CKD Anemia 2022 Project PI: @⁨Lupus 20F Patient Advocate⁩ ela unnaru 

Follow up ki epudu ostavu

[06/04/2025, 18:41] Lupus 20F Patient Advocate: Nice madam 12 ki vastha madam

[12/04/2025, 12:04] Rakesh Biswas: Reviewing now in OPD:

Asymptomatic after her last debacle when we had to admit her for recurrent abdominal pain and then stop her azathioprine assuming it's azathioprine induced recurrent pancreatitis!

Same sitting we also did her renal biopsy and now that she was out of sight and out of mind for a month we suddenly realised we didn't see that report! @⁨Pushed1Comm22⁩ @⁨Pushed Communicator 1N22⁩

[12/04/2025, 12:07] Rakesh Biswas: She's moving around with the tissue blocks which appears to have been provided to her by the Nalgonda lab where it was deposited!

Now please let's show these blocks to our pathology lab here in Narketpally campus

[12/04/2025, 12:22] Rakesh Biswas: Talked to the father just now @⁨Harika CKD Anemia 2022 Project PI⁩ @⁨Dr Ramji SR Medicine⁩ 

He deposited the renal biopsy tissue in that Nalgonda lab and paid the money but didn't collect any bill and yesterday once he reached that lab for the report they simply handed him this packet containing blocks!

[12/04/2025, 12:32] Pushed Communicator 1N22: Sir the pathologist at nalgonda said she usually dont report renal biopsy

So she sent back the blocks asking them to get reported at other center

[12/04/2025, 12:33] Rakesh Biswas: This is terrible isn't it! 😨

[12/04/2025, 12:34] Pushed Communicator 1N22: We asked the attender to collect the report multiple times in the past few weeks sir

We thought they are a bit busy and will come to us with the report

[12/04/2025, 12:39] Harika CKD Anemia 2022 Project PI: Yes sir  that tooo after repeated calls and msgs they went yesterday to collect the report sir

[12/04/2025, 12:41] Sai Charan Kulkarni 2020 KIMS Pg: In which lab sample was given Govt lab or Raju @ thyrocare..?

[12/04/2025, 12:41] Vivek Kurma 2022 KIMs Pg Med: Jagruthi diagnostics sir

[12/04/2025, 12:43] Pushed Communicator 1N22: At Thyrocare

They dont prepare the blocks and slides sir

[12/04/2025, 12:44] Sai Charan Kulkarni 2020 KIMS Pg: Usually we send biopsy samples to KHL right..? What made us to out source sample this time..?

[12/04/2025, 12:46] Vivek Kurma 2022 KIMs Pg Med: Contacted thyrocare now sir they said  they give report after 1 week with cost of 800 sir

[12/04/2025, 12:46] Rakesh Biswas: Why didn't we verify that Jagruti diagnostics doesn't do renal biopsy reporting?

[12/04/2025, 12:47] Rakesh Biswas: Now we are sending the blocks to our campus pathology. Not sure how much they charge

[12/04/2025, 12:48] Vivek Kurma 2022 KIMs Pg Med: Khl costs around 3k sir whereas in NLG it is costing around 1500 sir

[13/04/2025, 14:21] Rakesh Biswas: What about Narketpally?

To KHL we can send just the immuno florescence part?

Also from what we know now there's no expertise in Nalgonda to see these histopathology specimens particularly renal biopsy. I'm sure we may have a better light microscopy expertise here in Narketpally

[13/04/2025, 14:22] Rakesh Biswas: Why didn't we talk to Dr Krishna Chaitanya and ask where he would prefer to send his biopsies or where does he send his biopsies that he does in other centres

[17/04/2025, 11:23] Rakesh Biswas: Update:

Ultimately the biopsy was still sent to this lab instead of our own Narketpally lab!

[02/05/2025, 20:41] Rakesh Biswas: So @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ @⁨pajr.in CEO, NHS Endocrinologist⁩ is this Lupus nephritis class 2 or class 4?

[02/05/2025, 21:14] Sai Charan Kulkarni 2020 KIMS Pg: Yes sir mesangioproliferative in favour of grade 2 LN.

[02/05/2025, 21:15] Rakesh Biswas: So why did we/you have to treat her as class 4 Lupus at some point in 2022 end when she first presented to us?

[02/05/2025, 21:51] pajr.in CEO, NHS Endocrinologist: Clinical severity?

[02/05/2025, 22:15] Rakesh Biswas: Clinical class 4 reverting to class 2 or clinico pathologic dys-correlation?

[02/05/2025, 22:26] pajr.in CEO, NHS Endocrinologist: Likely the former.

[06/05/2025, 17:01] Rakesh Biswas: Update:

Admitted yesterday with vomiting and reduced appetite since 2-3 weeks after she stopped the prednisolone on her own and continued only the MMF!

@⁨Akash Deep Kims 2023⁩ please share her last two 24 hour urine for creatinine and protein. Her lupus nephritis may have also flared up now after her stopping the steroids. Her serum albumin has fallen to 1.8 and she also looks cachectic today

[07/05/2025, 15:05] Rakesh Biswas: Yesterday's intake output

3000 ml/20 ml

Pulse iv methyl prednisolone  today

[08/05/2025, 11:07] Rakesh Biswas: Apparently as per @⁨Akash Deep Kims 2023⁩ passed 120 ml yesterday on Day 2. Day 1 as mentioned earlier was 20 ml.

Received 750 mg of methyl prednisolone iv yesterday

[09/05/2025, 15:40] Rakesh Biswas: @⁨Harika 2024 Kims Medicine PG⁩ @⁨Anonymous Pm⁩ @⁨Jitendra Kims PG Med 24⁩ @⁨Meta AI⁩ @⁨Dr.Abdulsalam Med Ed Leads⁩  given that this patient's lupus nephritis has been smoldering since September 2022 when @⁨Sai Charan Kulkarni 2020 KIMS Pg⁩ @⁨pajr.in CEO, NHS Endocrinologist⁩ 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, 16:00] Dr.Abdulsalam Med Ed Leads: 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

[10/05/2025, 15:11] Rakesh Biswas: Today's update: urine output recovering

[10/05/2025, 15:11] Rakesh Biswas: I/O 2250/650

[12/05/2025, 11:53] Rakesh Biswas: Today's update from @⁨Parimala Gurram Kims 2024 PG Med⁩ :

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] Rakesh Biswas: @⁨Parimala Gurram Kims 2024 PG Med⁩ 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 DR MANOJ (ASST PROF) DR RAMBABU (SR)

DR PRACHETHAN (PGY3) DR HARIKA (PGY3)

DR AKASH (PGY2) DR PARIMALA (PGY1) DR HARIKA (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 ReactiveBLOOD 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/dlSGOT(AST) 19 IU/LSGPT(ALT) 12 IU/LALKALINE PHOSPHATASE 135 IU/LTOTAL

PROTEINS 3.7 gm/dl ALBUMIN 1.8 gm/dlA/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 normochromicWBC With in normal limits with increasedneutrophilsPLATELETS Adequate in number and distribution HEMOPARASITES No hemoparasites seen IMPRESSION Normocytic normochromic anemiawith neutrophilia

HIV 1/2 Rapid Test Non Reactive

24 HOURS URINEPROTEIN105 mg/day. <150 mg/day24 HOURS URINECREATININE0.5 g/day 1-3 gm /dayRATIO 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, 16:35] Dr.Abdulsalam Med Ed Leads: 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!

[16/05/2025, 21:46] Pushed Communicator 1N22: @⁨Rakesh Biswas⁩ 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] Rakesh Biswas: Can ask her to start lasix 40 mg from tomorrow morning