Case scenario 2: A 26-year-old female patient with a known medical history of HTN who presents with facial rash, oral sore, and sensitivity to light x 3 days.
Case scenario 2: A 26-year-old female patient with a known medical history of HTN who presents with facial rash, oral sore, and sensitivity to light x 3 days. She states that she has been experiencing a lot of family issues causing her to stress too much. She reports that she just recently started on hydralazine for her hypertension.
Subjective:
What other relevant questions should you ask regarding HPI?
When did the facial rash and oral sore first appear, and have there been any changes in their appearance over time?
Is there any associated pain or itching with the facial rash and oral sore?
Have you experienced any joint pain, muscle aches, or fevers in conjunction with the appearance of these symptoms?
Can you provide information about any recent infections, alterations in medications, or exposures to new substances that may be related to the development of the facial rash and oral sore?
What are the risk factors of this patient?
Evaluate the patient’s family medical history, paying particular attention to autoimmune diseases, with a specific focus on lupus. Explore recent stressors or emotional factors since stress can influence disease flares. Inquire about the patient’s medication adherence, specifically regarding hydralazine, and ask if there is any history of adverse reactions to medications.
Objective:
What would be the focus of your assessment?
Perform a comprehensive dermatological examination to thoroughly evaluate the characteristics of the facial rash and oral sores. Conduct a joint examination to identify any signs of arthritis. Assess the neurological status, including the examination of cranial nerves, to evaluate for potential involvement of the central nervous system. This multifaceted approach aims to gather detailed information about the patient’s condition and guide further diagnostic and therapeutic considerations.
Does the patient meet any of the SLICC Criteria for Lupus 2012?
The SLICC criteria aimed to improve sensitivity by incorporating numerous new elements and emphasizing two key principles: the necessity for systemic lupus erythematosus (SLE) diagnosis to include at least one clinical and one autoimmune measure, and the distinctive recognition of lupus nephritis, which, when biopsy proven, holds an independent diagnostic significance (Aringer & Petri, 2020). Common clinical criteria include mucous membrane ulcers, non-scarring alopecia, and photosensitivity. Immunologic criteria include the presence of antinuclear antibodies (ANA) or anti-dsDNA antibodies. Further assessment is needed in order to see if the patient meets the SLICC Criteria.
What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
Complete Blood Count (CBC): To assess for anemia, leukopenia, or thrombocytopenia.
Autoantibody Testing: Including ANA and anti-dsDNA antibodies.
Urinalysis: To check for proteinuria or hematuria.
Skin Biopsy: If the rash is unusual or not responsive to initial treatment.
The patient’s vital signs were as follows:
BP: 80/42
HR: 103
RR: 18
O2 sats: 97% on room air
Any additional tests would you order for this patient?
In the specific clinical setting, I might consider obtaining an electrocardiogram (ECG) and echocardiogram to assess for potential cardiovascular complications, especially if there are indications like chest pain, shortness of breath, or a diagnosed case of pericarditis.
Diagnosis:
Top 3 Differential Diagnoses and Rationale:
a. Systemic Lupus Erythematosus (SLE): The patient presents with characteristic features such as facial rash, oral ulcers, and photosensitivity. Positive autoantibodies would support this diagnosis.
b. Drug-Induced Lupus: Given the recent initiation of hydralazine, drug-induced lupus should be considered. Symptoms usually resolve upon discontinuation of the medication.
c. Vasculitis: The patient’s symptoms, including rash and oral sores, may be indicative of vasculitis. Further evaluation is needed to determine the underlying cause.
What is the patient’s final diagnosis?
The patient’s final diagnosis is consistent with Drug-Induced Lupus, considering the characteristic clinical features and the recent initiation of hydralazine. Drug-Induced Lupus syndrome manifests in 5–10% of individuals using hydralazine, and clinical symptoms encompass joint pain, muscle pain, fever, and inflammation of the serous membranes (Iyer et al., 2017).
Plan:
Gold Standard Treatment:
Stopping hydralazine would be the first management of Drug-Induced Lupus. Managing lupus typically entails a combination of corticosteroids and immunosuppressive medications to control symptoms and prevent flare-ups (Justiz Vaillant et al., 2020). Hydroxychloroquine may be prescribed to address skin and joint symptoms (Justiz Vaillant et al., 2020). Hydroxychloroquine is known for its efficacy in managing skin and joint symptoms associated with lupus and is often considered a cornerstone in the treatment of this autoimmune condition.
When would you consider consulting other services? Discuss your rationale.
Consider consulting Rheumatology for specialized management of autoimmune diseases. Nephrology may be consulted if there are signs of renal involvement. Also, if patient is pregnant, a consult obstetrician should be considered. Cardiology consult or primary care provider consult should be also considered to replace hydralazine.
What is your disposition? Admit vs. Discharge? Why?
Admission may be necessary if there is evidence of severe organ involvement, such as renal or cardiovascular complications, or if the patient is not responding to outpatient management. Close monitoring of the patient and the patient’s vital sign is crucial. Coordination with specialists may be best achieved through inpatient care, especially in the context of a new diagnosis of lupus. If the disease is stable and can be managed on an outpatient basis, discharge with close follow-up may be considered.
References
Aringer, M., & Petri, M. (2020). New classification criteria for systemic lupus erythematosus. Current Opinion in Rheumatology, 32(6). https://doi.org/10.1097/bor.0000000000000740
Iyer, P., Dirweesh, A., & Zijoo, R. (2017). Hydralazine Induced Lupus Syndrome Presenting with Recurrent Pericardial Effusion and a Negative Antinuclear Antibody. Case Reports in Rheumatology, 11(6), 5245904. https://doi.org/10.1155/2017/5245904
Justiz Vaillant, A. A., Goyal, A., Bansal, P., & Varacallo, M. (2020). Lupus Erythematosus. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK535405/
PEER 1 (EDA)
Hello classmates and professor,
Case scenario 2: A 26-year-old female patient with a known medical history of HTN who presents with facial rash, oral sore, and sensitivity to light x 3 days. She states that she has been experiencing a lot of family issues causing her to stress too much. She reports that she just recently started on hydralazine for her hypertension.
Answer the following questions:
Subjective:
What other relevant questions should you ask regarding HPI?
Have you had any fevers associated with your symptoms? If so, how high?
Have you noticed any changes in your hair, such as hair loss or balding?
Do you have any pain, swelling, or stiffness in the muscles and joints?
Have you been experiencing any fatigue?
Have you noticed the rash anywhere else in your body?
Where in your mouth do the sores appear? How often do they appear?
Have you had any memory problems or brain fog?
Have you noticed any unusual bruising?
Have you had any chest pain?
Do you have any family history of autoimmune diseases in the family?
What are the risks factors of this patient?
The risk factors for this patient include gender and age. Lupus is more common in women and is most usually diagnosed between their 20s and 30s. But other risk factors can include race and family history.
Objective:
What would be the focus of your assessment?
The focus of my assessment would be to get a good and thorough medical history. Making sure that I ask about the patient’s symptoms, when they began, and how long they last. I would also include questions about the patient’s family history or other autoimmune diseases. Do a complete physical exam that includes looking for rashes, mouth sores, or any other symptoms that may signify that something is wrong. And I would also include blood and urine tests.
Does the patient meet any of the SLICC Criteria for Lupus 2012?
Patient does meet some of the SLICC criteria. The features that she meets include having oral ulcers, and those of which are part of the acute cutaneous lupus category (photosensitivity, and rash).
What tests or procedures (Lab or Diagnostic) would you perform or order for this patient?
Tests I would order on this patient would include a complete blood count. Patients with lupus tend to have a lower hemoglobin, platelet count and or, white blood count. I would also order a sed rate, to see if the laboratory comes back elevated. For the most part, due to the inflammatory reasoning, this lab is often elevated. Since lupus can affect the kidneys and liver, I would also order labs to check for that too. In addition to lab work, I would also order a CMP, and a direct Coombs test. A urinalysis, as protein levels and red blood cells are seen in patients who have lupus. In addition, an ANA test will signify a stimulated immune system which can help in diagnosing patients with lupus, along with other labs as well. Lastly, diagnostic testing such as a chest x-ray or echo can help make sure the lupus hasn’t affected the lungs or heart.
The patient’s vital signs were as follows:
BP
80/42
HR
103
RR
18
O2 sats
97% on room air
Any additional tests would you order for this patient?
Being that the patient’s blood pressure was low, I would make sure that the lupus has not already caused so damage to the patient’s kidneys. We know that the patient has a history of hypertension which already places her at a higher risk for kidney problems. In addition, if the patient is not diagnosed with lupus yet, it can be that the hydralazine she is taking for her hypertension needs to be adjusted or changed. As a provider, I would make sure to order lab work such as a CMP, as well as a urinalysis to check for any protein or red blood cells. Unfortunately, lupus can cause cardiovascular problems so I would also maybe start off ordering an EKG and then an echo to check for any issues with her heart.
Diagnosis:
What are the top 3 differential diagnoses you would consider for this patient, and what is your rationale?
Sarcoidosis: like patients who have SLE, patients that have sarcoidosis, tend to have fatigues, fevers, rashes, and sensitivity to light caused by uveitis.
Lyme disease: like patients who have SLE, patients that have Lyme disease, can have erythema migrans, neuritis, and joint pain.
Systemic lupus erythematosus: although SLE can be difficult to diagnose because many of the symptoms are nonspecific and overlap with those of more common conditions. But with high suspicion, I would definitely use the SLICC criteria for SLE diagnosis.
What is the patient’s final diagnosis?
The patient’s final diagnosis is systemic lupus erythematosus (SLE).
Plan:
What is the gold standard treatment for this patient’s final diagnosis?
Most common treatment varies by patient and by their signs and symptoms. These treatments can include anything from NSAIDS, antimalarial drugs such as hydroxychloroquine, corticosteroids, immunosuppressants such as Imuran, biologics, and even some clinical trials as well.
When would you consider consulting other services? Discuss your rationale.
Yes, I would consider consulting a Rheumatologist as this is the doctor that specializes in patients with SLE. In addition, I would also consult a cardiologist, and nephrologist. Both of these doctors can help manage and treat any effects the lupus has done to the kidneys or heart of the patient.
What is your disposition? Admit vs. discharge? Why?
Being that the patient has not been diagnosed with lupus yet, but is suspected, I would admit the patient. For one, the patient stated she was under a lot of stress which places her at a high risk for a lupus flare up, which may require high doses of IV steroids. In addition, the patient’s blood pressure was very low indicating that a cardiac involvement may be happening. Both cardiovascular involvement and lupus flare ups, are some of the most common reasons for hospitalization.
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