Immunological: SLE

Patient: Ms. Jane Doe, a 35-year-old female Chief Complaint: Fatigue, joint pain, and rash History of Present Illness: Ms. Doe presents to her primary care physician with a 2-month history of fatigue, joint pain, and a rash on her face and chest. She also reports fevers, weight loss, and hair loss. She has no significant past medical history. Past Medical History: None Social History: Ms. Doe is a single, white female who works as a software engineer. She does not smoke or drink alcohol. Physical Examination:

• Vital signs: BP 140/90 mmHg, HR 100 bpm, RR 20 bpm, SpO2 98% on room air
• General: Well-developed, well-nourished female in no acute distress
• HEENT: Pupils equal, round, and reactive to light; Sclerae anicteric
• Neck: No jugular venous distension
• Lungs: Clear to auscultation
• Heart: Regular rate and rhythm, no murmurs, rubs, or gallops
• Abdomen: Soft, non-tender, non-distended; positive bowel sounds
• Extremities: 2+ pitting edema in bilateral lower extremities
• Rash: Discoid rash on face and chest

Laboratory Studies:

• Complete blood count: Within normal limits
• Blood chemistry: Sodium 135 mEq/L, potassium 4.0 mEq/L, chloride 100 mEq/L, bicarbonate 24 mEq/L, glucose 120 mg/dL, creatinine 1.0 mg/dL, BUN 15 mg/dL
• Creatinine clearance: 60 mL/min
• Urinalysis: Positive for protein, glucose, and blood
• Antinuclear antibody (ANA): Positive
• Anti-dsDNA antibody: Positive
• Complement C3: Decreased
• Complement C4: Decreased

Diagnosis: Systemic lupus erythematosus Treatment Plan:

• Medications:
  • Hydroxychloroquine
  • Prednisone
  • Methotrexate
• Lifestyle modifications:
  • Sun protection
  • Smoking cessation
  • Avoidance of stress
• Education:
  • Patient education about SLE and its treatment
  • Importance of taking medications as prescribed
  • Lifestyle modifications to reduce risk of further complications

Nursing Interventions:

• Monitor vital signs and fluid status
• Administer medications as prescribed
• Provide patient education about SLE
• Encourage lifestyle modifications to reduce risk of further complications

Discussion Questions:

1. What are the risk factors for SLE?
2. What are the laboratory and diagnostic findings that are consistent with SLE?
3. What are the medications that are commonly used to treat SLE?
4. What are the lifestyle modifications that can help to reduce the risk of complications from SLE?
5. What are the nursing interventions that are important for the care of a patient with SLE?

Conclusion: Ms. Doe is a 35-year-old female with a new diagnosis of SLE. She has been started on medications and has been given education about SLE. She will be monitored closely for further complications. Additional Information:

• SLE is a chronic autoimmune disease that can affect multiple organ systems.
• The exact cause of SLE is unknown, but it is thought to be caused by a combination of genetic and environmental factors.
• Symptoms of SLE can vary widely and can include fatigue, joint pain, rash, fever, weight loss, and hair loss.
• There is no cure for SLE, but it can be managed with medications and lifestyle modifications.

Sample Solution

History of Present Illness: Ms. Doe presents to her primary care physician with a 2-month history of fatigue, joint pain, and a rash on her face and chest.