CASE

PRESENTATION
 GENERAL DATA
Patient Name: A. C.
Sex: Female
Age: 43 years old
Civil Status: N/A
Occupation: OFW
Birthdate: December 31, 1976
Religion: Roman Catholic
Address: Toril, DavaoCity
 CHIEF COMPLAINT

Swelling of lower
extremities
 HPI
4 months prior to admission, patient had the onset
of on and off fever noted 38.7°C and was admitted at
Kuwait Hospital. It was associated with dry cough,
difficulty of breathing, chest pain and swollen right
supraclavicular lymph nodes. Patient underwent
biopsy of lymph nodes and was diagnosed with TB
lymphadenitis. Patient claimed that the sputum test
was negative for TB. Patient was given antibiotics and
paracetamol with no relief. Symptoms were not
associated with night sweats, blood-streaked phlegm,
and chills.
 HPI
2 months prior to admission, patient presented with
edema of lower extremities associated with fever,
dyspnea and easy fatigability hence admitted at private
hospital in Kuwait. Patient also claimed that she had
pleural and pericardial effusion associated with non-
radiating chest pain and severe headache. Patient also
claimed that sometimes she experienced joint pain but
it was not associated with stiffness, tender and warm
joint. Hair loss and rashes were not also noted.
 HPI
On the day of admission, patient seeks
consultation due to unresolved edema of lower
extremities and hip pain thus decided to be
admitted.
 PAST MEDICAL HISTORY

• non-hypertensive
• non-diabetic
• No history of cardiac problems, kidney
problems, and liver problems
• No history of any childhood illnesses and any
psychiatric illnesses
• She underwent thoracentesis to drain fluid in
pleura.
 PAST MEDICAL HISTORY
Hopitalization/Injury/Illness:

October 2019  Fever and swollen lymph

nodes
December 2019  Edema of lower
extremities

Allergies: Patient claimed that she had allergic reaction to house

paint. No food and drug allergies.
 
Gynecologic: Patient is G2P2. January 27, 2019 was the LMP.
Patient had regular menstruation using 2pads/day with no
dysmenorrhea.
 FAMILY HISTORY

• Patient’s sister died due to Lupus

• mother is hypertensive
• brother had a history of TB
• No family history of heart disease,
allergy, gout, arthritis, cancer, mental
illness, and thyroid disease.
 PERSONAL AND SOCIAL HISTORY

Patient is a non-smoker and non-

alcoholic drinker with good
interrelationship with her two
daughters. She is a single parent OFW
and does not follow any specific diet.
 REVIEW OF
SYSTEMS
General (+)weight loss
(+) fatigue
Skin (-) rash (-) hair abnormalities
(-) dryness of skin (-) nail abnormalities
(-) itching (-) photosensitivity
Eye (-) lacrimation (-) pain
(-) itching (-) redness
(-) astigmatism
Ears (-) discharge
(-) pain
Nose and sinuses (-) pain
(-) obstruction
(-) discharge
 REVIEW OF
SYSTEMS
Throat and Mouth (-) sores (-) white patches
(-) fissures (-) tonsillitis
Neck (-) lumps
(-) pain
(-) swollen glands
Respiratory (-) cough (-) wheezing
(-) crackles (-) hemoptysis
(-) dyspnea
Cardiovascular (-) palpitations
(-) syncope
(-) pain
Gastrointestinal (-) ulcer
(-) loss of appetite
(-) diarrhea
 REVIEW OF
SYSTEMS
Urinary (-) dysuria
(-) discharge
(-) polyuria
Musculoskeletal (-) backache (-) cramps
(+) muscle or joint pain (+) swelling
(-) trauma
Neurologic (-) dizziness
(-) seizures
Psychiatric (-) mood changes
(-) anxiety
Hematologic (-) anemia
(-) bruising
Endocrine (-) heat or cold intolerance
(-) diabetes
 PHYSICAL EXAMINATION

General description: Patient was examined

conscious, alert and oriented. Patient was able to
answer questions and perform physical
examination but with difficulty of sitting and
standing. She has IV line on her left arm.
 PHYSICAL EXAMINATION
Vital Signs
• Blood Pressure: 110/60 right brachial artery, supine
(normal)
• Temperature: 36.2C left axillary, supine (normal)
• Respiratory Rate: 25cpm diaphragmatic, supine
(tachypneic)
• Pulse Rate: 64bpm right radial artery, supine (normal)
Anthropometric Measurements
• Weight: 59 kg
• Height: 160 cm
• BMI: 23 kg/m2 (normal)
 PHYSICAL EXAMINATION
Skin: Inpection: Skin is in normal color. No scars and
lesions noted on the extremities. No clubbing of nails,
rashes, pallor and discolorations.
Palpation: The skin was warm to touch. Unable to pinch
the skin of lower extremities.
 
Head: Inspection: No bruises and swelling noted on
her head. Scalp had no lesions and the hair was well
distributed, fine and no pattern of hair loss.
Palpation: No tenderness or masses felt upon palpation of
the skull and scalp.
 PHYSICAL EXAMINATION
Eyes: Inspection: Sclera appeared white but conjunctiva
looks pale. No edema or lesions in the eyelids. No nodules or
swelling in the conjunctiva and sclera. Pupils were equally round
and reactive to light accommodation. No opacities of the cornea.
Eyebrows and eyelashes are symmetrical and evenly distributed.
Palpation: No tenderness noted on periorbital area.
Ear: Inspection: Auricles are symmetrical in size and shape.
No deformities, lumps, lesions and discharges noted.
Palpation: Movement of the tragus and palpation of post-
auricular area were not painful. Ear are firm and non-tender. Tug
test is unremarkable.
 PHYSICAL EXAMINATION
Nose: Inspection: Septum is midline and no alar
flaring.
Palpation: No tenderness in all sinuses.
Mouth: Inspection: Lips were pale and dry with no
excoriations. Oral mucosa and gums were pinkish. No
ulceration of mucosa. No bleeding and swelling in the
gums. Teeth appeared white in color. The tongue was
pinkish and symmetrical, smooth texture of the dorsum
of the tongue. Tongue was in midline and no deviation
was observed. The floor of the mouth appeared pinkish.
Tonsils were not enlarged. Uvula is in midline and no
deviation.
 PHYSICAL EXAMINATION
Neck: Inspection: Scars were noted at right supraclavicular
area. No any anterior neck mass noted and neck veins were not
distended.
Palpation: Trachea is in the midline. Thyroid gland not enlarge and
non-tender.
Lymph nodes:
Preauricular: (-) tenderness, Submandibular: (-) tenderness,
Posterior auricular: (-) tenderness, Submental: (-) tenderness,
Occipital: (-) tenderness, Superficial cervical: (-) tenderness,
Tonsillar: (-) tenderness, Posterior cervical: (-) tenderness , Deep
cervical: (-) tenderness, Supraclavicular: (-) tenderness

Clavicle: Intact and no fracture

 PHYSICAL EXAMINATION
Chest&Lungs:Inspection: Symmetrical chest with no
visible deformities or lesions. There were no abnormal
retractions or other impaired respiratory movements.
Palpation: No tenderness felt upon palpation. Symmetrical
chest expansion and tactile fremitus were equally felt on
both lungs.
Percussion: Lung fields were resonant.
Auscultation: Normal breath sounds were heard. No
adventitious sounds such as crackles, wheezes and rhonchi.
 
Breast: Not assessed.
 PHYSICAL EXAMINATION

Cardiac: jugular venous pressure was measured 7 cmH20

Inspection: No cyanosis was noted. Jugular vein was
not distended.
Palpation: PMI was palpated at the 5th intercostal space
midclavicular line.
Auscultation: No murmurs heard.
 PHYSICAL EXAMINATION
Abdomen: Inspection: Abdominal contour was globular. No
abdominal masses, scars, lesions or abnormal pigmentations noted.
Auscultation: Hyperactive bowel sounds.
Percussion: Liver dullness in midclavicular line. Abdomen
was tympanic upon percussion.
Palpation: No kidney tenderness felt over the right and left
costovertebral angles. No tenderness of the entire abdomen. No
guarding or rigidity of abdominal muscles.
Other tests:
(-) Murphy’s sign (-) Psoas sign
(-) Rovsing’s sign (-) Obturator sign
 PHYSICAL EXAMINATION

Musculoskeletal:
Inspection: Pitting bipedal edema of lower
extremities was observed with no redness noted.
Swelling of fingers were also noted but with no
lesions. No joint deformities.
Palpation: No tendernes noted.
 PHYSICAL EXAMINATION
Peripheral vascular system:
Inspection: No pallor and swelling noted.
Pulses Brachi Radial Femoral Popliteal Dorsalis
al pedis
Right 2+ 1+ Not Not 2+
assessed assessed
Left 2+ 2+ Not Not 2+
assessed assessed
Tourniquet test: Not assessed

Genital and rectal exam: Not assessed.

 PHYSICAL EXAMINATION
Neurological:
Cerebellar tests: Patient was able to perform rapid alternative
movements with her hands in normal speed and uniform rhythm.
Patient accurately performed the finger to nose test with no tremors.
Heel to shin tests was not performed. Patient could sit and stand with
difficulty.
Cranial nerves:
CN I: Patient can distinguish smells and no nasal obstructions.
CN II: Pupils are in equal size and both reactive to light and
accommodation.
CN III,IV,V: Extraocular muscles were intact and the patient can follow
the movement of the fingers.
CN V: Facial sensation and corneal reflex were intact. Able to clench
 PHYSICAL EXAMINATION

CN VII: Patient was able to raise eyebrows, frown, close eyes and
smile.
CN VIII: Patient was able to hear whispered voice and was able to
repeat the letters and numbers.
CN IX,X: Patient was able to swallow with no difficulty, there was
rise of palate in the “Ahh test” and intact gag reflex.
CN XI: Patient was able to raise shoulders and move neck in the
opposite direction with or without resistance.
CN XII: Tongue was symmetrical and is not deviated; it was present
in the midline.
 PHYSICAL EXAMINATION
Sensory system: No involuntary movements noted. Sensation to
light touch is intact.
Motor system: No tremors, fasciculation or ticks noted. No atrophy
or wasting of muscles.

Ankle Ankle
Knee
Grip Finger Thumb dorso plant
flexion
  Elbow Wrist strengt abductio oppositio - ar-
and
h n n flexio flexio
extension
n n
Right 5/5 5/5 4/5 5/5 5/5 5/5 5/5 5/5
Left 5/5 5/5 4/5 5/5 5/5 5/5 5/5 5/5
 PHYSICAL EXAMINATION

Deep Tendon Reflexes:

  Bracior
Biceps Triceps Knee Ankle Plantar
adialis
Right 2+ 2+ 2+ Not Not Not
assessed assessed assessed
Left 2+ 2+ 2+ Not Not Not
assessed assessed assessed
 SALIENT FEATURE
Pertinent Positives Pertinent Negatives
 Female  No hair loss
 43 years old  No skin rashes
 Pitting edema of lower extremities  No kidney problems
 No liver problems
 Swelling of fingers (puffy fingers)  No joint deformities
 Fever  No tenderness of joint
 Weight loss  No redness of joint
 Pale conjunctiva  No finger lesions
 Dry lips  No redness of eyes
 Fatigue  No oral ulcers
 Family history of Lupus  
 Pleural effusion  
 Pericardial effusion  
 Non-radiating chest pain
 Severe headache
 Occasional hip joint pain
 Dry cough
 Dyspnea
 Swollen supraclavicular lymph nodes
 INITIAL IMPRESSION

Systemic Lupus Erythematosus

 DIFFERENTIAL DIAGNOSIS
Disease Rule in Rule out
Rheumatoid Arthritis  Fever  No redness of joint
 Fatigue  No tenderness of joint
 Occasional hip joint pain  No joint deformities
 Cardiac complications  
(pericardial effusion)
 Lung complications
(Dyspnea)
 Sex (female)
Mixed Connective Tissue  Fever  No skin rashes
Disorder  Fatigue  No kidney problems
 
 Swelling of fingers (puffy
fingers)
 Pale conjunctiva
 Dry lips
 Occasional hip joint pain
Systemic Sclerosis (Scleroderma)  Lung complications  No finger lesions
(Dyspnea)  No hair loss
 Dry cough  No kidney problems
 Occasional hip joint pain  
 Cardiac complications
(pericardial effusion)
 DIFFERENTIAL DIAGNOSIS
Sarcoidosis
Systemic Lupus Erythematosus
 Dry cough  No rashes
 Fever  No liver problems
 Lung complications (Dyspnea)  No kidney problems
 Fatigue  No redness of eyes
 Swollen supraclavicular lymph  
nodes  
 Swelling of fingers (puffy fingers)
 Cardiac complications
(pericardial effusion and chest
pain)
 Sex (female)  No hair loss
 History of Lupus  No oral ulcers
 Fatigue  No rashes
 Severe headache
 Swelling of fingers (puffy fingers)
 Occasional hip joint pain
 Pale conjunctiva
 Dry lips
 Weight loss
 Cardiac complications
(pericardial effusion and chest
pain)
 Lung complications (Dyspnea)
 FINAL DIAGNOSIS

Systemic Lupus Eythematosus plus

Sarcoidosis