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). A patient can be diagnosed with SLE if that
patient fulfills 4 of 11 criteria in the 1997 ACR, have 4 of 17 criteria of the 2012 SLICC or has a
biopsy proven nephritis compatible with SLE in the presence of ANA or anti-dsDNA antibodies [
CITATION Per20 \l 1033 ]. This patient has 6 of 11 criteria of the 1997ACR.
Brief 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 rash started on her cheeks and nose and progressed to her
forearms and chest. She feels like it started with sun exposure. 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 a 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.
Status/Condition:
•
Stable
Code Status:
•
Full Code
Allergies:
•
NKDA
Admit to Unit:
•
Medical Surgical
Activity Level:
•
Up as tolerated
Diet:
•
Regular diet
IVF:
•
0.9% NS at 75/hr
Critical Drips: n/a
Respiratory:
•
Monitor O2 saturations, oxygen therapy as needed per protocol. Incentive spirometer
education to prevent pneumonia [ CITATION Fer19 \l 1033 ].
