30 y/o female w/ SOB

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30 years old female presented to casualty with 

chief complaints of sudden worsening of SOB since one day 

History of presenting illness:

patient was apparently normal till six years back in 2017 she had generalised body aches and joint pains which involves multiple large joints of which elbow And knee joints  troubled her associated with generalised body aches after multiple hospital visits 

she even noticed hair loss without scarring and oral ulcers then she was diagnosed with autoimmune disorder and initiated on hydroxychloroquine azathioprine wysolone  

she reported that her joint pains and hair loss was not improving  with the above medication she had multiple hospital visits and admissions for joint pains and body aches which bothers her from doing her activities .

Two months back she had pedal edema  two months back she had pedal edema  sudden onset shortness of breath initially on exertion then she was diagnosed with hypertensive emergency admitted and discharged with antihypertensive . patients stopped AZA as advised by doctor  except hyper antihypertensive since yesterday she had shortness of breath initially on exertion which rapidly progressed to sob at rest 

No small joint pains no colour change /paraesthesia so fingers on exposure to cold

New onset of seizures :Patient had one episode of involuntary movements initially started left-hand followed by total body with impaired consciousness no  tongue bite   no involuntary maturation or defecation yesterday

Personal history:

daily routine a day starts at 7 AM after breakfast work starts from 9 AM attending client calls with 1 to 2 breaks in between till 6 PM more of sedentary work 

Diet - mixed

Appatite-loss of appetite

Sleep- adequate

Bowel and bladder - regular

No  Addictions

Past history :

Two months back she had pedal edema  two months back she had pedal edema  sudden onset shortness of breath initially on exertion then she was diagnosed with hypertensive emergency admitted and discharged with antihypertensive since 10 days .

Patient got dialysis done three times one month back 

Insertion site : femoral region

O/e:

Patient  conscious coherent cooperative

 BP presentation to 220/140 MMHg given NTG and Nicardia ___BP-160/100 MMHg

PR-134bpm

RR-36cpm___24cpm

SpO2-236mg/dl

GRBS-236mg/dl

General physical examination :

 Pallor present

 flat nails

 non-scarring alopecia 

 hyperpigmented discoid rashes on face  Periauralblack discolouration of oral mucosa and palate 

Mild pedal edema 

CVS :

 no raised JVP

S1 S2 +

no murmurs

RS:

BAE +

diffuse  inspiratory and expiratory crepts

P/A: 

Soft and non-tender

 mild distended

 umbilicus inverted

 no organomegaly

CNS:

HMF intact 

E4V5M6

Pupils NSRL

 no FND(last seizure episode )

Labs :normocytic normochromic anaemia with leukocytosis

Diagnosis : 

ACUTE CARDIOGENIC PULMONARY EDEMA with Immune mediated Glomerulonephritis.

SEIZURES SECONDARY TO ?PRES/?Uremia/? vasculitis.

Rx:

1.Inj. LEVIPIL 500mg IV TID

2.INJ.NTG 50 mg in 50 ml NS @5ml/hr to maintain SBP-<160mmhg

3. INJ.LASIX 40mg IV BD

4.TAB.NICARDIA RETARD 20mg PO BD

5.TAB.OROFER -XT PO/OD 

6. Tab.HCQ 200mg PO BD

7.fluid and salt restriction

8. Monitor vitals and inform sos

9.INJ.HAI S/C acc to GRBS inform ICU /PG@ 7 point profile GRBS

10. Strict I/O Charting

11.TAB.MET XL 25mg PO BD

12. TAB.TELMA 40 mg PO/OD

13.TAB .WYSOLONE 20mg /PO/OD