General Data: M.

R, 32/F, residing in Navotas, , Roman Catholic

Chief Complaint: Body ache on the whole body and fingers

History of Present Illness:

2 weeks prior to consult, the patient felt sudden onset of pain mostly on the left elbow and right knee and
fingers swelling and no limitation to movement. The patient characterizes the pain as 3-4/10. The pain
disappears when she is at rest.

1 week prior to consult, the symptoms of pain on left elbows, right knee, and fingers persist with additional
symptoms of fever of 38C which occurs everyday and relieves while taking Paracetamol 500mg every 4
hours however the returns after. It is associated with dry cough; patient has no odynophagia and no
dysphagia. The patient started taking Alaxan 500 mg 3x a day and Amoxicillin 500mg 2-3x a day for joint
pain but was not effective. The patient pain scale increased to 8-10, her work is affected which prompted
her to consult.

Past Medical History:

Patient had childhood illness of chickenpox but cannot recall when she was infected.
No adult illnesses(?)
Has Covid-19 vaccination with 2 doses of Moderna, no booster
No measles, mumps
No hospitalizations
No allergies
No other medications or vitamins
Personal and Social History:
 Patient smokes 1-2 sticks a day and started when she was 14 years old
 Occasionally drinks alcohol such as gin.
 Works as a secretary for 2 years
 Lives in a house with 1 room and 1 window, the house is located between the road and river
 The patient’s diet involves bread or fried rice for breakfast while for lunch and dinner she eats rice
with fish, meat or vegetables.
 Denies taking illegal drugs

Gynecologic History:
Last Menstrual Period: 12 years old
Duration: Irregular started when she was 25 years old, her menstruation would last 2-5 days
Uses 3-4 napkin pads
No dysmenorrhea, not using contraceptives

Family History:
Mother: Age is approximately 70 years old with complication of hypertension and goiter no medications
given

Father: Age is approximately 70 years old with complication of hypertension, no medications given

The patient has 3 older sibling with no medical complications

Review of Systems:
General: (-) weight loss, (+) fatigue, (-) changes in hair or nails, (-) excessive sweating
Skin: (-) rashes, (+) redness when exposed to sunlight, (-) skin lesions, (-) changes in color, (-) hair loss
HEENT: (-) dizziness, (-) headache, (-) blurring of vision, (-) dimming of vision, (-) epistaxis, (-) tinnitus, (-)
loss of hearing, (-) bleeding of gums (-) sore throat, (-) neck stiffness
Breast: (-)
Respiratory: (-) cough, (-) dyspnea, (-) wheezing, (-) no hemoptysis
Cardiovascular: (-) chest pain, (-) orthopnea, (-) palpitations, (-) edema
Genitourinary: (-) dysuria, (-) changes in urine character or amount, (-) changes in menstrual flow, (-)
vaginal discharge, (-) hematuria, (+) frothy urine
Endocrine: (-) heat/cold intolerance, (-) polyuria, (-) polydipsia, (-) polyphagia, (+) proteinuria

PHYSICAL EXAMINATION

The patient is conscious, coherent, alert, ambulatory

BP=160/100, HR=90/min, RR=20/min, T=37.8C
Skin: Rashes around the face and neck
Pale palpebral conjunctivae, anicteric sclerae, (-) cervical lymphadenopathy, (-) anterior neck mass, (-)
neck vein distention
Equal chest expansion, no retractions, decreased breath sounds both basal lungfields
(-) heaves/thrills, AB at 5th LICS MCL, S1>S2 at apex, (+) gr 2/6 systolic murmur at the apex
globular abdomen, normoactive bowel sounds, soft, nontender, liver span 8cm at right midclavicular line,
intact Traube’s space
warmth and tenderness, right knee and left-hand fingers
(+) gr 2 bipedal edema, full pulses

INTERPRETATIVE SUMMARY.
Our patient is a 32/F who complains of body aches and fingers. 2 weeks prior to consult, the patient felt
sudden onset of pain mostly on the left elbow and right knee and fingers swelling and no limitation to
movement. She characterized the pain to be around 3-4/10 on pain scale. The is relieved when the
patient is at rest. 1 week prior to consult, the pain persists with additional symptom of fever of 38C which
is relieved by taking Paracetamol 500mg every 4 hours but the fever returns after, it is associated with dry
cough with no dysphagia or odynophagia. She self-medicated with Alaxan 500 mg 3x a day and
Amoxicillin 500 mg 2x-3x a day for joint pain did not relieve the pain. The pain is now at 8/10 on pain
scale and her work is affected which prompted her for consultation. On past medical history the patient
had a childhood illness of chickenpox but cannot recall when she was infected. The patient had no
allergies, no hospitalizations, and no adult illnesses however she noted that she an increased blood
pressure. On personal and social history, the patient is a smoker started at age 14 for 1-2 sticks a day
and an occasional alcoholic drinker usually drinks gin or Emperador. On family history the mother is
around 70 years old with complications of hypertension and goiter, cannot recall the year of diagnosis and
medications. The father is also around 70 years old with complications of hypertension, cannot recall the
year of diagnosis and medications. Her live-in partner is 34 years old who is healthy and her 3 older
siblings are also healthy. On gynecologic history the patient currently has irregular menstruation with the
longest interval is 4 months with the duration of menstruation of 2-3 days and amount is 3-4 pads. The
patient’s coitarche is 20 y/o and had 3 sexual partners, patient did not use condoms or birth control pills.
The patient had no history of STD and HPV, did not have pap smear done and associated pain on
menstruation. No pertinent findings on ROS. On PE the patient is hypertensive, decreased breath sound
on both basal lung fields on respiratory exam, grade 2/6 systolic murmur at the apex upon cardiac
auscultation, patient’s extremities, specifically right knee and left-hand fingers, were warm and tender,
and a grade 2 bipedal edema were noted. The history and physical exam show that the patient most likely
has systemic lupus erythematous.
DIAGNOSIS
Primary Working Impression: Systemic Lupus Erythematous
Differentials: Rheumatic heart fever
Rheumatic arthritis

DISCUSSION
The patient most likely has SLE due to her clinical history of sudden onset of joint pain on the left
elbow and right knee, fever, frothy urine, fatigue, and photosensitive rash with physical findings of
hypertension, malar rash on the face and neck, decreased breath sounds, systolic murmur and grade 2
bipedal edema are consistent with the findings for SLE.

The risk factors involved in SLE are environmental factors such as ultraviolet light, demethylating
drugs, and infectious or endogenous viruses or viral-like element, epigenetic factors such as DNA
methylation and post-translational modifications of histones that can be due to familial inheritance or
environmental, and hormonal factors such as oral contraceptive use and increased estrogen and prolactin
levels. These factors can cause immune dysregulation where increased amounts of apoptosis-related
endogenous nucleic acids stimulate the production of IFNα and promote autoimmunity by breaking self-
tolerance through activation of antigen-presenting cells. This can cause immune complexes to amplify the
inflammatory response such as fever.

Then tissue damage is mediated by recruitment of inflammatory cells, reactive oxygen

intermediates, production of inflammatory cytokines, and modulation of the coagulation cascade. The
immune complexes would then deposit onto joints that can cause arthritis. Homocysteine and
proinflammatory cytokines, such as IFNα, impair endothelial function which can cause vascular damage
and decrease endothelial repair this can cause complication of carditis and can affects the structure of the
heart. This is presented by the patient of grade 2/6 murmur

Immune complexes can also affect the kidneys which can result in proteinuria as presented in the
patient to have frothy urine which indicates renal involvement which is called lupus nephritis. This can
also cause elevated blood pressure and edema which are present in the patient.

SLICC Criteria for SLE lifted from UpToDate

The diagnosis should be based on both clinical findings and laboratory evaluations. In the SLICC
criteria for diagnosis of SLE the patient met 4 out of 11 clinical criteria which are acute cutaneous lupus,
arthritis, photosensitive rash, and proteinuria via frothy urine. However, no immunologic criteria were met
since the case did not present any laboratory findings as of now. Four out of these criteria should be met,
including at least 1 clinical criterion and 1 immunologic criterion to consider SLE.
 The first differential I considered was rheumatic hear fever because of the complaint of the patient
of joint pain on the left elbow and right knee, fever, grade 2/6 cardiac murmur, difficulty breathing and
bipedal edema. However, I ruled out that based on the Jones criteria other major criteria such as
erythema marginatum which should not present rash on the face, and subcutaneous nodules are not
present in the patient.

Lastly, second differential I considered was rheumatic arthritis, I ruled it in due to the complaint of
the patient of joint pain on the left elbow and right knee, swelling fingers and fever. However, I ruled this
out because the patient had other clinical presentation of difficulty breathing, grade 2/6 cardiac murmur
and proteinuria and did not present stiffness and limited range of movement.

PROBLEM LIST and MANAGEMENT PLAN

1. Joint pain
 Diagnostics and Laboratories
o Upper extremity and knee X-ray- to check for joint involvement and swelling
 Therapeutics
o Non-pharmacologic: rest and exercise
o Pharmacologic: NSAIDS such as diclofenac or acetaminophen,
Hydroxychloroquine 200 to 400 mg/day if SLE is confirmed, Glucocorticoids for
persistent arthritis, Methotrexate
2. Fever
 Diagnostics and Laboratories
o CBC- check for presence of infection, and check signs of anemia, leukopenia
and thrombocytopenia
 Therapeutics
o Monitor body temperature
o Paracetamol 500mg to relieve fever
3. Malar rash on face and neck
 Diagnostics and Laboratories
o Allergen test
o Anti-dsDNA titers- highly specific for SLE
o ANA immunoassay- used to diagnose SLE; 100% sensitivity and
86%specificity
 Therapeutics
o Non-pharmacologic: reduce sun exposure, use sunscreen protection
o Pharmacologic: topical corticosteroids, Hydroxychloroquine 200 to 400 mg/day,
mycophenolate, prednisone 30-50mg per day
4. Decreased breath sounds
 Diagnostics and Laboratories
o Chest X-ray- check for opacity or infiltrates
o Pulmonary function tests
 Therapeutics
o Supportive therapy such as exercise and oxygen supply
5. Cardiac murmur, hypertension and Grade 2 bipedal edema
 Diagnostics and Laboratories
o Monitor blood pressure
o 2D-Echocardiography
 Therapeutic
 o Pharmacologic: Hydroxychloroquine 200 to 400 mg/day, nonsteroidal anti-
inflammatory drug (NSAID) or glucocorticoid as first-line therapy. Prednisone
30-50mg per day
o
6. Frothy urine
 Diagnostics and Laboratories
o Serum creatinine- check kidney function
o Urinalysis- check for proteinuria or cellular casts and hematuria may be due to
presence of lupus nephritis.
o Protein-to-creatinine ratio – Quantification of proteinuria helps assess the
severity of glomerular disease
 Therapeutics
o Pharmacologic: Mycophenolate daily dose of 2 to 2.5 g or
IV cyclophosphamide administered 500 mg every two weeks for a total of six
doses, prednisone 30-50mg per day
o Follow-up 2 to 4 weeks for 3 months to evaluate response to therapy and
toxicity via history taking and laboratory tests

References:

Christie M Bartels, M. D. (2022, April 28). Systemic lupus erythematosus (SLE). Practice Essentials,
Pathophysiology, Etiology. Retrieved May 4, 2022, from
https://emedicine.medscape.com/article/332244-overview

Wallace, D. J., & Gladman, D. D. (2022, April 22). Clinical manifestations and diagnosis of systemic lupus
erythematosus in adults. UpToDate. Retrieved May 4, 2022, from
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-lupus-
erythematosus-in-adults?
search=systemic+lupus+erythematosus&source=search_result&selectedTitle=1~150&usage_type=
default&display_rank=1

Wallace, D. J., & Gladman, D. D. (2022, April 22). Overview of the management and prognosis of
systemic lupus erythematosus in adults. UpToDate. Retrieved May 4, 2022, from
https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-systemic-lupus-
erythematosus-in-adults?
search=systemic+lupus+erythematosus&source=search_result&selectedTitle=1~150&usage_type=
default&display_rank=1

Jameson JL, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J, eds. Harrison's Principles of
Internal Medicine. 20th ed. McGraw Hill; 2018.

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PERSONAL REFLECTIONS: Please include this reflection in your written report.

1) Please rank the following components for this activity from 1-5 (with 1 being the easiest, 5
hardest):
1-bedside history-taking and physical exam
5-discussion of differential diagnosis
4-generating problem list and plan
3-organizing case presentation
2-organizing written report
2) What made your #1 activity easy? What made your #5 activity difficult?
- The number 1 was much more easy since I can interact with the patient and establish rapport
to the patient. Also I can observe her while doing history taking and since this is a group
activity I get to talk with my classmates on what information to get or check for missing
information. Number 5 was difficult for me since the disease covers a lot of the principles
involving SLE which affects a lot of the organs and the differentials overlap with each other.

3) What improvements can you make for your performance in the next activity?
- Improve my communication skills when facing the patient and establish eye contact to the
patient. Making sure to practice organizing my notes. In the discussion to make sure to
correlate the clinical presentation with the criteria in diagnosing the disease and to memorize
treatment and management of different diseases.