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31 year old male who is a photographer by occupation came to the casuality with complaints of Yellowish discolouration of sclera since 4 days ,Fever since 2 days which is insidious on onset , gradually progressive , subsided on medication. C/o Nausea and vomitings since 2 days Non -bilious and non projectile , food particle as content and was taken to local hospital in view of vomitings .
Patient was apparently asymptomatic 17 years back then his mom observed hypopigmented patch over the cheek , and multiple hypopigmentation patches areas all over the body , neglected thinking it was due to vitamin deficiency , 15 days back mother observed a hypopigmented patch on the right arm and took him to a local hospital and was diagnosed with hansens and was on treatment since then.
No complaints of shortness of breath, palpitations , headache , orthopnea, PND .
Non - Alcoholic
Non - Smoker
On examination
Patient is conscious coherent co operative
Oriented for time place and person
Pallor ++
Icterus ++
No cyanosis
Clubbing or lymphadenopathy
Febrile : 99.9
Bp: 130/80mmhg
PR: 83 bpm regular normal volume
CVS : s1s2 no murmurs
Rs : NVBS + no crepts
P/A: mild splenomegaly + BS +
CNS :
Tone : Rt Lt
UL N N
LL N N
Power : Rt Lt
UL 5/5 5/5
LL 5/5 5/5
Reflexes :
B S T A K P
Rt. 2+ 2+ 2+ 2+ 2+ F
Lt 2+ 2+ 2+ 2+ 2+ F
Sensory :
Fine touch : present
Crude touch : present
Lost sensation over the hypopigmented lesion on lower limbs
Intact sensation over the lesions on forearm & neck
(Touch , pain & temperature were intact over forearm & neck lesions
Lost pain & touch over lower limb lesions)
Diagnosis :
DRUG INDUCED HEPATITIS
BORDERLINE LEPROMATOUS LEPROSY
Treatment given:
1.TAB.UDILIV 300 MG/PO/BD
2.TAB.RIFAXIMINE 550 MG/PO/BD
3.SYP.LACTULOSE 10ML/PO/TID
4.INJ.PANTOP 40 MG/IV/OD
5.INJ.ZOFER 4MG/IV/SOS
6.IVF NS AND RL @50 ML WITH 1 AMP OF OPTINEURON IV/OD
7.MONITOR VITALS 2ND HRLY
DOA: 26/04/22
SOAP NOTES AMC DAY 1:
S
Yellowish discoloration of sclera since 4 days
Fever since 2 days
O
GENERAL EXAMINATION:
Patient is conscious,coherent, co operative
Oriented to time ,Place, Person
VITALS :
Temp 98.6 F
BP: 120/80mm hg
PR: 95bpm
RR: 17cpm
PER ABDOMEN EXAMINATION:
Mild Splenomegaly+
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1, S2 heard
RESPIRATORY SYSTEM:
BAE present, NVBS
CNS :NAD
Hb- 10.6
Urine bile salts and bile pigments positive
LDH 868 IU/L
Total bilirubin 7.82
Direct bilirubin 5.63
AST 401
ALT 580
ALP 208
A
DIAGNOSIS :
DRUG INDUCED HEPATITIS
?BORDERLINE LEPROMATOUS LEPROSY
P
1.TAB.UDILIV 300 MG/PO/BD
2.TAB.RIFAXIMINE 550 MG/PO/BD
3.SYP.LACTULOSE 10ML/PO/TID
4.INJ.PANTOP 40 MG/IV/OD
5.INJ.ZOFER 4MG/IV/SOS
6.IVF NS AND RL @50 ML WITH 1 AMP OF OPTINEURON IV/OD
7.MONITOR VITALS 2ND HRLY
SOAP NOTES AMC DAY 2:
S
Yellowish discoloration of sclera+
No fresh complaints
O
GENERAL EXAMINATION:
Patient is conscious,coherent, co operative
Oriented to time ,Place, Person
VITALS :
Temp 98.4 F
BP: 110/80mm hg
PR: 90bpm
RR: 18cpm
PER ABDOMEN EXAMINATION:
Mild Splenomegaly+
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1, S2 heard
RESPIRATORY SYSTEM:
BAE present, NVBS
CNS :NAD
DVL referral: BORDERLINE LEPROMATOUS LEPROSY
Ophthal referral: B/L Heterochromia iridis
Direct Coombs test Negative
USG: No sonological abnormality detected
Today LFT(28/04/22)
MADDREYS DISCRIMINATORY SCORE: 21.3
A
DIAGNOSIS :
DRUG INDUCED HEPATITIS SECONDARY TO BORDERLINE LEPROMATOUS LEPROSY
P
1.NORMAL DIET
2.TAB.UDILIV 300 MG/PO/BD
3.SYP.LACTULOSE 10ML/PO/TID
4.INJ.PANTOP 40 MG/IV/OD
5.INJ.ZOFER 4MG/IV/SOS
6.IVF NS AND RL @50 ML WITH 1 AMP OF OPTINEURON IV/OD
7.SYP.HEPAMERZ 10 ML/PO/TID
8.FUDIC CREAM L/A
9.MONITOR VITALS 2ND HRLY
10.INJ.VIT K 1 AMP IN 100ML NS
SOAP NOTES AMC DAY 3:
S
Yellowish discoloration of sclera+
No fresh complaints
O
GENERAL EXAMINATION:
Patient is conscious,coherent, co operative
Oriented to time ,Place, Person
VITALS :
Temp 98.4 F
BP: 110/80mm hg
PR: 86bpm
RR: 16cpm
PER ABDOMEN EXAMINATION:
Mild Splenomegaly+
Bowel sounds present
CARDIOVASCULAR SYSTEM:
S1, S2 heard
RESPIRATORY SYSTEM:
BAE present, NVBS
CNS :NAD
On 29/04/2022:
Slit skin smear and skin biopsy done
MADDREYS DISCRIMINATORY SCORE: 21.3
A
DIAGNOSIS :
DRUG INDUCED HEPATITIS SECONDARY TO BORDERLINE LEPROMATOUS LEPROSY
DAPSONE SYNDROME
P
1.NORMAL DIET
2.TAB.UDILIV 300 MG/PO/BD
3.SYP.LACTULOSE 10ML/PO/TID
4.INJ.PANTOP 40 MG/IV/OD
5.INJ.ZOFER 4MG/IV/SOS
6.IVF NS AND RL @50 ML WITH 1 AMP OF OPTINEURON IV/OD
7.SYP.HEPAMERZ 10 ML/PO/TID
8.FUDIC CREAM L/A
9.MONITOR VITALS 2ND HRLY
10.INJ.VIT K 1 AMP IN 100ML NS
11.Tab.Omnacortil 20mg OD/PO after mrng breakfast.
12 .Tab.Omnacortil 5 mg OD/PO after dinner.
1/05/22
SOAP NOTES AMC BED -2
S -
Yellowish discoloration of sclera +
No fresh complaints
O- Patient is consious, co-herent, co-operative
No icterus,odema,cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.1F
Pulse rate - 84BPM, REGULAR, NORMAL VOLUME
BP -
@8AM-120/70MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
CVS -S1,S2 Heard
RS-BAE+
CNS-NAD
P/A-Mild Splenomegaly+
Bowel sounds present
A
DIAGNOSIS-
DRUG INDUCED HEPATITIS
?BORDERLINE LEPROMATOUS LEPROSY
P-
1.IVF NS @75ML /HR WITH 1 AMP OF OPTINEURON IV/OD
2.INJ VIT K 1 AMP IN 100ML NS/IV/OD
3.TAB.UDILIV 300 MG/PO/BD
4.TAB OMNICORTIL 20MG PO/OD O-×
TAB OMNICORTIL 5MG PO/OD X-O
5.TAB ANTOXID PO/OD 2PM
6.TAB HEPTAGON PO/OD 2PM
7.SYP.LACTULOSE 10ML/PO/TID
8.FUDIC CREAM L/A
2/05/22
SOAP NOTES AMC BED -2
S -Yellowish discoloration of sclera +
No fresh complaints
O- Patient is consious, co-herent, co-operative,
No icterus,odema,Q cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 99.4F
Pulse rate - 78BPM, REGULAR, NORMAL VOLUME
BP -@8AM-120/80MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
CVS -S1,S2 Heard
RS-BAE+
CNS-NAD
P/A-Mild Splenomegaly+
Bowel sounds present
A
DIAGNOSIS-
DRUG INDUCED HEPATITIS
?BORDERLINE LEPROMATOUS LEPROSY
P-
1.IVF NS @75ML /HR WITH 1 AMP OF OPTINEURON IV/OD
2.INJ VIT K 1 AMP IN 100ML NS/IV/OD
3.TAB.UDILIV 300 MG/PO/BD
4.TAB OMNICORTIL 20MG PO/OD O-×
TAB OMNICORTIL 5MG PO/OD O-O
5.TAB ANTOXID PO/OD 2PM
6.TAB HEPTAGON PO/OD 2PM
7.SYP.LACTULOSE 10ML/PO/TID
8.FUDIC CREAM L/A
SOAP NOTES AMC BED -2 3/05/22
S -yellowish discoloration of sclera +
No fresh complaints
O- Patient is consious, co-herent, co-operative,
No icterus,odema, cyanosis, clubbing, lymphadenopathy.
VITALS :
Temperature - 98.6F
Pulse rate - 82BPM, REGULAR, NORMAL VOLUME
BP -@8AM-120/80MM OF HG
SPo2 - 98%@RA
SYSTEMIC/ EXAMINATION -
CVS -S1,S2 Heard
RS-BAE+
CNS-NAD
P/A-Mild Splenomegaly+
Bowel sounds present
A
DIAGNOSIS-
DRUG INDUCED HEPATITIS
? HANSENS DISEASE
P-
1.IVF NS @75ML /HR WITH 1 AMP OF OPTINEURON IV/OD
2.INJ VIT K 1 AMP IN 100ML NS/IV/OD D5
3.TAB.UDILIV 300 MG/PO/BD
4.TAB ANTOXID PO/OD 2PM
5.TAB HEPTAGON PO/OD 2PM
6.SYP.LACTULOSE 10ML7/PO/TID
7.FUDIC CREAM L/A
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