CHUA, Precious Diamond C.

Grp 6A

Dr. Llamado

Name: n/a 17M

Birthdate: n/a 1998
Address: Tondo, Manila
Confinement Dates: n/a
Hospital Number: n/a
Diagnosis: Systemic Lupus Erythematosus with lupus nephritis
Discharge Summary

Six weeks PTA: diagnosed with pneumonia thru CXR accompanied with fever of 6 weeks (highest temperature of
40.5oC), erythematous rashes on face and extremities, dry cough and bubbly urine. Rx: IV cefuroxime,
ciprofloxacin, paracetamol no improvement with persistence of fever and worsening of cough. Four weeks PTA:
managed as dengue hemorrhagic fever with episodes of gum bleeding, productive cough with occasional blood
streaked sputum. CBC showed thrombocytopenia (71), hgb 126 WBC 3.6 no improvement. Two weeks PTA: with
persistence of symptoms accompanied with painful toes and pitting edema on the right leg, and tea-colored urine.
CBC resulted hgb 105 WBC 3.8 platelet 210; BUN 12.8 creatinine1.22 Na 139.5 K 5.17 ESR 92; typhidot negative.
Rx: empiric anti-tuberculosis regimen (HRE) referred to USTH for further evaluation.

Present admission due to referral. Admission PE: BP 140/100 RR 26 CR 116 T 37.7C BMI 18 wheelchair borne.
Maculopapular rashes with scabs and crusts on the neck, upper and lower extremities and face. Pale palpebral
conjunctivae, bilateral cervical and inguinal lymphadenopathy, oral ulcers with whitish plaques on hard palate and
gum bleeding. Dullness, decreased fremiti and decreased breath sounds on both lower lung fields. Tender joints
with full ROM, unilateral pitting edema on right lower extremity, with positive Homans sign. Hgb 85, WBC 3.7 and
platelet 196 with reticulocytosis. Urine albumin 4+, RBCs 15-20, hyaline and granular casts. Urine protein :
creatinine(UPC) ratio 1.65. BUN 32.78, serum creatinine 0.96, albumin 1.83, globulin 4.1, A/G ratio 0.4, Na 137 and
K 4.93. CXR: bilateral pleural effusion. Thoracentesis obtained 520 cc of yellowish with slight greenish turbid fluid
with WBC 811, protein 3.47, LDH 418.55. Pleural fluid cultures, sputum smears for AFB and blood cultures no
growth. Venous duplex scan of the lower extremities showed extensive thrombosis of the right external iliac vein,
common femoral vein, deep femoral vein, superficial femoral vein, popliteal vein, peroneal vein, anterior and
posterior tibialis vein. ANA 1:320 (+), anti-ds DNA 1:20; C3 0.15.PT 12.3 with INR of 1. HIV (-).

Course: Given co-amoxiclav 1.2g BID, low molecular weight heparin (LMWH) overlapped with warfarin 2.5 mg OD,
enalapril 5 mg OD, hydroxychloroquine 200mg/day, calcium supplement, methylprednisolone pulse 1g and first
dose of cyclophosphamide pulse therapy. Discharged and slightly improved.

Discharge medication: prednisone 60 mg/day for maintenance, cyclophosphamide pulse therapy

Other instructions: return for follow-up

Submitted by: PDC
Attending physician: LJL
Date: 09 Mar
2015

REFLECTION
While reading the protocol, I realized that doctors should be careful in diagnosing
patients. Careful history, physical examination and appropriate ancillary procedures are
needed to confirm the right diagnosis and treat the patient. Every time doctors commit a
mistake with the diagnosis would greatly affect the patient.
During the CCC, I was enlightened that there are different types of fever of
unknown origin namely classic, nosocomial, neutropenic and HIV associated FUO. Also,
the similarities or overlapping clinical manifestations of SLE and AIDS patients have been
discussed; now we are more aware of the significance of knowing the patients risk
factors. Ethics regarding HIV has been tackled thoroughly. A lot of questions were raised
by the students as well as doctors. There were many questions in the back of our minds
still left unanswered. This means that HIV concept for us, especially students is still

very vague. We still have to learn a lot from the experiences of doctors regarding this
issue. It is still a taboo. The bottom line is we should treat HIV patients similarly with
other patients that is with utmost respect and dignity.