37yr old with skin lesions

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Chief complaints:-

Itchy skin lesions all over the body since 8 months 

History of present illness:-

Patient was apparently alright 8 months back then he developed small papules over the cheek after which it transformed into erythematous scaly plaques first on the nose and cheek then over the entire face,neck,back,hands and legs.

H/o itching over the plaques

H/o photosensitivity 

C/o Tenderness in wrist joint, metacarpophalangeal joint,interphalangeal joint 

H/o fever 4 episodes in last 8 months,last episode 20 days back.fever lasts for one day releived after taking medication.

H/o oral ulcers on hard palate since 10days

No chest pain,sob, palpitations

No abdominal pain,nausea vomiting 

No increased or decreased output 

 PAST HISTORY:

H/o cva, left UL ,LL weakness and slurred speech 10 years back 

H/o appendectomy 8 years back 

Used ayurvedic medicine 1 month back for 15 days.

 Not a known case of diabetes mellitus, hypertension, tuberculosis, asthma, epilepsy

Family history:- not significant 

Personal history:- 

Appetite:- decreased since 3 days

Diet:- mixed

Sleep :- adequate

B& B :- regular 

 Addictions :- toddy drinker since 20 years 

Bedi smoker since 25 years(15 per day)

General examination:- 

Patient is conscious, coherent, cooperative well oriented to time place and person .

Moderately built, moderately nourished

Pallor:- absent 

Icterus:- absent 

Cyanosis:- absent 

Clubbing:- absent

Generalized lymphadenopathy:- absent

Bilateral pedal edema :- absent 

Vitals:- 

Bp:100/70 mmhg 

Pulse rate:-80 bpm 

RR:- 18 cycles per min

Temp :- afebrile

Systemic examination:-

CVS

  s1,s2  are heard no murmurs

 Per Abdomen :- soft ,non tender 

Shape of the abdomen -flat

Umbilicus -central

Bowels sounds are heard

Respiratory system 

Shape of the chest -elliptical

Trachea-central

 bilateral air entry present 

NVBS are heard

CNS :

Higher mental functions:normal

Memory intact

Cranial nerves:normal

Sensory examination:normal sensations felt in all dermatomes

Motor examination:normal tone in both upper and lower limb

Normal power in both upper and lower limb

Reflexes:

Normal,brisk reflexes elicited-biceps,triceps,knee,ankle

Cerebellar function:normal 

No meningeal signs were elicited

Investigations:- 

 x - ray :-

Provisional diagnosis:-

Systemic lupus erythematous,viral pyrexia with bicytopenia(thrombocytopenia,leukopenia)

Treatment:- 

SUNCROS AUQAGEL SPF 50 L/A

MUCOPAIN GEL L/A TID

T.PCM 650 MG PO TID

T.BENFOMET PLUS PO OD