How can I help you today? I haven’t been feeling great lately, I fell really tired. Ive had a rash on face x1 month, Fevreish. Hands and knees stiff and hurt.
Any other symptoms we should discuss? Ya now my chests been
...
How can I help you today? I haven’t been feeling great lately, I fell really tired. Ive had a rash on face x1 month, Fevreish. Hands and knees stiff and hurt.
Any other symptoms we should discuss? Ya now my chests been hurting an five been feeling SOB.
Eevnts around start of fever? I am not sure. All seems to have some after my trip to florida
Events surrounding start of chest pain. The CP was last thing to start. Couple of days ago. At first rwally mild but now cannot ignore it. Rates 7/10. Worsened pain with deep inspritation. Alliviated with sitting up.
Knee pain worse with bending or clombing stairs. 3/10
Hand apin worse with trying to grab glass or open door. Tylenol doesn’t do much. 3/10. Pain sort of deep indside my small joints. Both hands equally.
No changes in family Hx. No recent infection. Up to date with immunizations. Preforms breast exams. Takes Tylenol
PE:
Skin: Erythematous raised conlfueny rash over cheeks (malar distribution) and forehead; sparing of nasolabial folds. Similar rash to forearms and upper/anterior chest
Hair: normal distribution and thickness
Eyes: PERRLA
Mouth: no oral mucosal lesions or tonsillar exudate
Lymph nodes: bilateral distribution of palpable, small ( less than or equal to 1 cm), soft, mobile, nontender lymph nodes: cervical, axillary, inguinal
Abdomen: active BS
Extremities: erythematous, raised, confluent rash over forearms. Symmetric swelling and erythema of the metacarpophalanges and proximal interphalangeal joints. Bilateral anterior knee swelling. Symmetric edema and tenderness of the metacarpophalanges and proximal interphalangeal joint. Small bilateral knee effusions. Bilateral +1 pitting edema of the level of the knees.
Range of motion. Reduced MCP’s, PIPs, and knees due to tenderness, not obstruction.
Neuro. DTRs intact
Musculoskeltal: good strength
HPI:
Patricia Doyle is a 21 y/o female who presents to the clinic today with complaints of fever and rash. She also has associated symptoms of fatigue, pain and stiffness to her hands and knees, shortness of breath and chest pain. She feels her symptoms began approximately 2 weeks ago after taking a vacation to Florida. She states her fever has been elevated to a little over 100 degrees that comes and goes. Her knee and hand pain is rated at a 3/10 and is worsened with movement such as climbing stairs or turning a door knob. She becomes short of breath with exertion and had an episode of increased shortness of breath with laughing. Her chest pain began last, couple of days ago, and has progressively worsened from mild to being unable to ignore. She rates her chest pain at a 7/10 that is worsened with deep inspiration and has some alleviation with sitting up. She has been taking Tylenol but has had minimal relief of her symptoms.
Primary Diagnosis:
• Systemic Lupus Erythematosus (SLE): Chronic inflammatory disorder characterized by autoantibody production responsible for antibody-mediated and immune complex deposition tissue damage (Ferri, 2019).
Status/Condition: (Critical, Guarded, Stable, etc.)
• Guarded
Code Status:
• Full Code
Allergies:
• NKDA
Admit to Unit:
• Med-Surg Unit
Activity Level:
• Up as tolerated
Diet:
• Regular Diet
IVF
• NS at 75 ml/hr
Critical Drips:
• N/A
Respiratory:
• May use oxygen therapy up to 2L NC for comfort. Notify if requiring more support.
Medications:
• Tylenol 650 mg PO Q6H for pain
• Hydroxychloroquine 200 mg PO daily. Antimalarials (hydroxychloroquine) may be helpful in treating lupus rashes or joint symptoms and appear to reduce the incidence of severe disease flares (Papadakis & McPhee, 2018).
• Methyl prednisone 25 mg IV Daily: 0.5 mg/kg/day IV (Ferri, 2019).
Nursing Orders:
• Vital signs Q4H
• Strict I&O
• Notify if HR >120, BP <100 or >160.
• Up as tolerated
• Notify of any mental status changes
• Notify of worsening chest pain
Follow Up Lab tests:
• BMP Daily. Evaluate renal function and electrolytes.
• CBC daily. Anemia
• 24-hour urine protein collection if proteinuria (Ferri, 2019).
Diagnostic testing:
Completed studies:
• Antinuclear antibody (ANA) 1:512; Positive
• Rheumatoid Factor: Negative
• ESR 90; elevated
• HIV Antibody: Negative
• Creatinine Kinase; Normal
• CBC
o Hgb 10.4, Hct 31, MCV 92; Normocytic Anemia
o Leukopenia 3000
o Thrombocytopenia 125
• UA revealed:
o Proteinuria
o 10 RBCs
o Positive occult blood; Microscopic hematuria. Initially, the kidneys may "leak" protein from the blood into the urine. When severe, this can cause water retention, swelling in the feet and lower legs, and other changes referred to as the nephrotic syndrome (Wallace, 2018).
Order Studies:
• Electrocardiogram: Chest Pain
• CXR: Evaluate SOB/Chest Pain
Consults:
• Rheumatology: New diagnosis of SLE
• Dermatology consultation for patients with unexplained or unusual skin rash (Ferri, 2019).
• Nephrology consultation in patients with proteinuria (Ferri, 2019).
Patient Education and Health Promotion (address age appropriate patient education if applicable):
• Use a sunscreen with a sun-protection factor (SPF) of 50 or greater every day, even if you don't plan to spend a lot of time outdoors. The sunscreen should be applied 30 to 60 minutes before going outside and should be reapplied every four to six hours (Wallace, 2018).
• If you have swelling (edema) in your feet or lower legs, decrease the amount of salt and sodium in your diet (Wallace, 2018).
• Follow a healthy diet.
• Vaccines to prevent pneumonia and the flu are recommended for people with lupus (Wallace, 2018).
• Women with lupus are at increased risk of miscarriage; however, the majority of women with lupus who get pregnant are able to carry to term (Wallace, 2018).
• Birth control methods if not trying to get pregnant at this time.
• Take all prescribed medications unless otherwise told by your doctor.
Discharge planning and required follow-up care:
• Discharge anticipated within 2-3 days
• Follow up with Rheumatology per their recommendations
• Follow up with dermatology per their recommendations.
• Follow up with nephrology per their recommendations.
• Follow up with PCP within 1 week of discharge
• Patient will be discharged on oral prednisone. 0.5 – 1 mg/kg/day prednisone x 4-6 weeks, tapered to 0.125 mg/kg every other day within 3 months (Ferri, 2019).
References:
Ferri, F. F., & Ferri, F. F. (2019). Ferris clinical advisor 2019: 5 books in 1. Philadelphia, PA: Elsevier.
Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2018). Current medical diagnosis & treatment (57th ed.). New York, NY: McGraw Hill
Wallace, D. (2018, February). Patient education: Systemic lupus erythematosus (SLE). Retrieved from https://www.uptodate.com/contents/systemic-lupus-erythematosus-sle-beyond-the-basics#H11
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