A Flare To Care.pptx

A flare to care A Case Presentation

AI  female  GENERALIZED 27 y/o  single  Solsona  INC

BODY WEAKNESS th 6 admission

 intermittent fever with diaphoresis Generalized body weakness Dizziness Mycophenolate mofetil 500 mg BID Knee pain brusing30 mg OD  Easy Prednisone  malar Caltraterash plus 500 mg OD  amennorhea FeSO4 and folic acid OD, dosage unrecalled alopecia

Diagnosed case of SLE 2013

INTERIM

2 weeks PTA

 Symptoms were recurrent  Managed by rest & adherence to medications  Symptoms non-tolerable: Consult

 Generalized body weakness  Managed by rest but still felt weak  No consultations

4 days PTA

 Same symptoms still present  Follow-up check-up at the OPD  CBC – low Hgb  Refused to be admitted

 Symptoms have not subsided yet Few hours  Consulted  Admitted PTA

Past Medical History (-) measles Childhood (-) chicken pox (-) mumps

(+) hypertension managed with Amlodipine 10mg OD highest BP 210/110 (-) diabetes mellitus, liver disease, asthma

Medical

Menarche: 14 y/o Obstetrics regular til 18 y/o without dysmenorrhea

Surgical

Psychiatric

Allergies

(-) history of surgeries (-) accidents (-) falls

denied any history of psychiatric illness

(-) known allergies to food or medicines

Heredofamilial (+) hypertension (-) kidney disease (-) stroke (-) diabetes mellitus (-) thyroid & liver disease (-) cancer (-) congenital disease (-) asthma (-) SLE Infectious (-) TB (-) Hepatitis

Family History

Personal History  College Undergraduate

 Lives with her parents and 5 siblings – with good interpersonal relationship  Currently manages their own sari-sari store  Non-smoker  Non alcoholic beverage drinker  Source of Stress prior to and during appearance of symptoms – OJT (kitchen staff)

Review of Systems General: + weight loss , no fever Skin: no lumps, no sores, + change in color Head: no headache, + dizziness, + lightheadedness Eyes: + blurring of vision, no pain, no redness, no excessive tearing Ears: no hearing loss, no tinnitus, no vertigo, no earaches, no discharges Nose and Sinuses: no colds, no nasal stuffiness, no discharge, no itching, no epistaxis Mouth/Throat: no bleeding gums, no dentures, no sore tongue, dry mouth, no sore throat, no hoarseness; (+) oral ulcers Neck: no swollen glands, no pain, no stiffness

Review of Systems Breast: no lumps, no pain, no discharge Cardiovascular: no chest pain, no palpitations GI: no dysphagia, no heartburn, no poor appetite, no nausea, no vomiting, no abdominal pain, no pain on defecation, no diarrhea, no constipation Peripheral Vascular: no pain, no leg cramps, no swelling Urinary: no frequency, no urgency, no polyuria, no nocturia, no pain, no incontinence, no hesitancy, no dribbling, no hematuria, no flank pain

Review of Systems Musculoskeletal: no muscle pain, + joint pain, no stiffness, no swelling, + paresthesia Psychiatric: no nervousness, no tension, no depression, no memory change Neurologic: no mood changes, no slurring of speech, no dizziness, no headache, no paralysis, no numbness Hematologic: + anemia, + easy bruising, no bleeding, (+) previous blood transfusion Endocrine: No heat intolerance, no cold intolerance, no polyphagia, no polyuria, no polydipsia, no increased sweating

Physical Examination General Survey: Awake, coherent, not in CP distress Vital signs: BP = 160/100 mmHg T = 37.3 oC HR = 117 bpm RR = 18 cpm O2 saturation = 99%, room air

Anthropometrics: Height: 148 cm Weight: 45 kg BMI: 20.5 – Normal

Physical Examination

Skin, Nails: Fair complexion, with discoid rash on the extensor surface of both arms, hematoma on left anterior forearm, dry, smooth, with good skin turgor, pale nail beds, palmar pallor, no pitting nails, no clubbing of digits, CR of < 2 secs.

Physical Examination

HEENT: Head: (+) Non-scarring alopecia, no mass, no tenderness Eyes: Pale palpebral conjunctiva, anicteric sclera, no hemorrhage Ears: No auricular tenderness; acuity good to whisper voice Nose: Patent, pink nasal mucosa, septum in midline, no sinus tenderness Mouth and throat: Dry pinkish lips; pinkish gums and buccal mucosa; uvula in midline; tongue midline without fasciculation, no mouth sores/ulcers, no gum bleeding, unenlarged tonsils, non-hyperemic, no exudates

Physical Examination Neck: no visible pulsations on carotid artery, no neck vein distention, no CLAD, non-enlarged thyroid glands no tenderness; no carotid thrills and bruits Back, Thorax, Lungs: Symmetrical chest expansion. Resonant on both lungs. Breath sounds heard on all lung fields. No crackles, no wheezes noted. Cardiovascular: Adynamic precordium, no heaves, no thrills, PMI at 5th ICS MCL. Tachycardic, regular rhythm. No murmurs heard. Abdomen: Globular, no visible pulsations, no visible blood vessels, no bulging flanks, normoactive bowel sounds, tympanitic, no palpable masses, soft non-tender, no CVA tenderness.

Physical Examination

Peripheral Vascular: radial, brachial, popliteal, dorsalis pedis pulses all normal (+2) Musculoskeletal: Gait: normal Arms: normal ROM Limbs: normal ROM Spine: No obvious deformities

Physical Examination Neurological Examination GCS: E4V5M6 (15) Mental Status: Alert, cooperative Cerebrum: oriented to time, place and person Cranial nerves: CN I = not assessed CN II = pupils equally round reactive to light 2 mm, (+) ROR, intact visual acuity, visual field full CN III, IV, VI = EOM intact, no nystagmus CN V = intact sensation, motor not tested CN VII = no facial asymmetries, taste not assessed CN VIII = intact gross hearing CN IX, X = able to swallow without difficulty CN XI = shrugs shoulder, turn head side to side CN XII = tongue midline, no atrophy

Physical Examination

Motor: 5/5 on all extremities Sensory: 5/5 on all extremities Reflexes: not assessed

Age Gender: Female Environmental Triggers

Salient Features

Clinical Manifestations

SYSTEMIC LUPUS ERYTHEMATOSUS, ACTIVE

Algorithm in the Diagnosis of SLE

Skin

Systemic Lupus International Collaborating Clinic (SLICC) Criteria for Classification of SLE

(Acute, Subacute, Chronic Cutaneous LE)



Oral Ulcer



Alopecia



Synovitis



Renal (Prot/Cr ≥0.5, RBC casts, Biopsy)



Neurologic



Hemolytic anemia



Leukopenia (<4000) or Lymphopenia (<1000) Thrombocytopenia (<100,000)

In flare but not in despair ABELLON ▪ CASTILLO ▪EROJO ▪ LABASAN ▪ LORENZO ▪ ROLDAN