Soap Note
yuselmartin
LupusSoapNote6.docx2 LUPUS
Student Name: Yusel Martin Pacheco
Miami Regional University
Course MSN5700C
Fall/ 2021
Professor: Miriam Alvarez
Preceptor: Idaylis Morono-Ponce
PATIENT INFORMATION
Encounter Date: 11/12/2021
Patient: H.M
Age: 39 years-old
Race: African
Gender: Female
Insurance: PPO
SUBJECTIVE
Chief complaint: “I have been experiencing fever, joint pains, a rash and reduced urine output.
History of Presenting Illness: the patient is a 39-year-old African female who presents to the clinic with complaints of a fever, joint pains, a rash and significantly reduced urine output. She also complains of a general feeling of weakness and fatigue. The symptoms began a week ago. She reports that the rash is mostly at the sun-exposed areas of her skin and worsens when she is exposed to the sun for long periods of time. The rash is worse around her cheeks where she also experiences redness. She has also noticed a significant amount of weight gain over the past few months and she wakes up in the morning with a swollen face and feet.
Patient Medical History:
Conditions: The patient was diagnosed with hypertension one year ago which persisted after having preeclampsia in her second pregnancy. She has no other known chronic illnesses.
Current medications:
She is currently taking lisinopril 10 mg daily and she is compliant on medication. She is not taking any Complementary and Alternative medicine.
Hospitalization: She has been hospitalized for 2 caesarean section deliveries one three years ago and the other one year ago and during that period she was in hospital for management of preeclampsia.
History of mental illness: She reports that she had an episode of major depressive disorder 5 years ago after the passing away of her mother for which she was managed. As of now she is stable and is not having any sad or suicidal thoughts.
Physical falls or trauma: The patient denies trauma or falls.
Surgeries: the patient has had two caesarean sections. the first one was due to placenta previa and the second one was due to obstructed labor compounded with preeclampsia. The patient denied any transfusion.
Environmental exposure: the patient claims that she lived near a mine two years ago and they had to move after she developed some respiratory problems due to exposure to the dust.
Exercise: She reports that she goes for morning jogs at least three times a week and goes swimming with her family every weekend.
Diet: She states to have been eating healthy diet after she had hypertension. Although they sometimes order fast foods when they are too tired to cook.
Social History: She is married with 2 children, 1 daughter and 1 son. She lives happily with her family. Her husband is alive and well with no known chronic illnesses. She denies using any recreational drugs like heroin and cocaine. She used to smoke but she stopped two years ago when she developed serious respiratory problems. She takes a bottle of beer once every two days and a glass of wine on weekends. She likes spending time with her friends and going out on weekends with her family.
Toxic Habits: the patient reports that she is not involved in any other toxic habits at the moment apart from the occasional beer and wine she takes.
Educational Level: She completed University level with a degree in commerce; she works as a banker.
Sexual behavior: The patient is heterosexual/straight with only one partner, her husband. She has been faithful to her husband after marriage.
Allergies: She has no known drug allergy. The patient usually develops allergic rhinitis especially during the summer which she manages with antihistamines. She is also allergic to eggs.
Family Medical History: Father is alive with hypertension and diabetes type 2. She reports that her mother passed away three years ago due to lupus-related complications. Her children are alive and healthy.
Preventive Services:
Last annual physical exam: 12/6/2020
Immunizations: Flu vaccine 09/7/2021 and COVID-19 vaccine- 20/04/2021. All her immunizations are up to date.
Review of Systems (ROS)
Systemic: the patient has been experiencing weight changes, general body weakness and fatigue.
Head: The patient reports multiple episodes of headaches over the past few months. denies dizziness or light headedness. No history of seizures or tremors, no history of loss of consciousness, no head injury.
Neck: The patient denies having pain in the neck and stiffness at the neck. She has no swellings on the neck.
Eyes: No blurred vision, no diplopia, no changes in her vision, No presence of secretions and redness.
Breasts: No discharge and pain, or any other symptom.
Cardiovascular: Patient complains of chest pain, and occasional difficulty in breathing, she has no paroxysmal nocturnal dyspnea. No tachycardia.
Pulmonary: denies productive cough, no hemoptysis. Patient denies wheezing and having shortness of breath, or dyspnea.
Gastrointestinal: The patient has been experiencing vomiting, nausea, abdominal discomfort/pain, no diarrhea or flatulence. She complains of constipation once in a while, No hematochezia.
Genitourinary: the patient reports a significantly reduced urine output over the past few months with the color of urine being an intense yellow. There are no blood stains in the urine. No other abnormal discharge noted, no changes in frequency or urgency of urination. The patient also reports to have experienced morning facial puffiness and lower limb oedema.
Endocrine: No polyphagia, no polyuria, no endocrine symptoms
Hematologic: The patient denies increased hunger and thirst, denies prolonged bleeding, no color change in nails, she gets tired easily and reports her hands and feet look pale, no hair loss/alopecia.
Musculoskeletal: the patient has joint pains especially at the wrist and ankle joints. The patient denies hearing a snapping or clicking sound on the joints, denies difficulty in walking, complains having problems with mobility when she is tired. She also complains of a dull ache in the muscles which sometimes increases with intensity.
Neurological: the patient complains of multiple episodes of headache. The patient denies dizziness denies balance problems, no tremors, denies feeling lightheadedness, no migraine, denies numbness and muscle weakness.
Psychological: the patient denies having insomnia or sleeping problems; however, shortness of breath sometimes makes her have troubles with sleep, denies feeling depressed, anxiety or restless, no change in her rhythm of thoughts.
Skin: the patient complains of a rash especially in the sun-exposed areas of her body and it worsens when she is exposed to the sun for long periods. She also has a reddening and rash over her cheeks.
Vital Sign:
BP cuff size: Regular
BP-sitting L: 143/91 mmHg
Pulse Rhythm: Regular
Pulse Rate-Sitting: 79 bpm
Respiration Rate: 17 per min
Oxygen Saturation: 97% on room air
Temp-Tympanic: 97.8 F
Height: 5’4”
Weight: 75 kg
Pain Rate/Scale: 3/10
General Appearance: Pleasant. Not in acute distress, patient is cooperative, active, well-nourished and well-developed. No apparent health issues.
Head: Normal hair pattern and distribution, symmetric, atraumatic or normocephalic. Symmetrical nasolabial folds, no facial drop. Slight puffiness of the face noted.
Neck: neck is supple, with a negative Brudzinski sign, no lymphadenopathy, trachea midline. No jugular vein distention.
Eye: Intact and normal visual acuity and extraocular eye movements, no scleral icterus, no conjunctiva discharge, pink conjunctiva, white sclera, symmetric eye movements, presence of bilateral periorbital edema. 20/20 distant and near vision. Pupil are equal reactive to light and round. Optic disc with clear margins, fundoscopic exam normal, no nystagmus, no strabismus.
Ears: Cone of light noted, Tympanic membranes intact bilaterally, ear canals clear bilaterally with no edema or lesions.
Nose: non-moist nasal mucosa, no clear discharge, no erythema, no lesions, nontender sinuses, septum midline.
Oral cavity: moist and pink mucosa Gums: no swelling, no bleeding, normal appearance. Teeth: good dentition and normal appearance of teeth.
Pharynx: No lesions, no swellings, no petechial, moist and pink pharynx, no exudate or erythema.
Tongue: midline tongue.
Lymph nodes: no swelling of lymph nodes.
Respiratory: no wheezes, no respiratory distress, normal air entry, normal breath sounds. Bilateral clear lungs, no rhonchi and no rales. Normal AP chest diameter and shape, No consolidation signs of tactile, fremitus or egophony.
Cardiovascular: normal S1S2 and regular rhythm.
Gastrointestinal: tenderness and guarding noted, no masses, no hepatosplenomegaly, bowel sounds present in all quadrants, non-distended abdomen,
Genitourinary: no swelling or discoloration, normal appearance of the genitals, no erythema or lesions, no foul smell or purulent discharge.
Rectal: Rectal assessment deferred.
Musculoskeletal: swelling and tenderness on the right wrist more than the left, with reduced range of motion. There is also swelling and tenderness at the ankle joints bilaterally with reduced range of motion. Bilateral pitting oedema of the lower limbs to the level of the knees .Normal motion range in the other joints, no obvious deformities, normal gait,
Neurological: Normal CNII-XII. No gross focal, Oriented and Alert x4, Bilateral UE/LE strength 5/5, neutral mood, intact sensation to bilateral upper and lower extremities.
Skin: a discoid rash noted all over the skin on sun-exposed areas, the rash has no oozing. A malar rash noted on the cheeks and over the nasal bridge.
Hair: slight thinning and hair loss noted on some areas of the scalp.
Nails: Normal appearance of nails, no onychomycosis, pink nails noted.
ASSESSMENT
Primary Diagnosis:
Systemic lupus erythematosus (ICD 10: M32.9): systemic lupus erythematosus is an autoimmune condition that occurs when the body is triggered to produce autoantibodies against most of the cells in the body. It results when there is a defect in the programmed cell death in the body hence leading to a disturbance in immune tolerance and the body develops immune attack against healthy cells in the body. This eventually leads to non-specific symptoms like fatigue, fever, general body weakness and other system-specific symptoms like renal failure, joint pains, a malar rash on the cheeks and nasal bridge, photosensitivity and discoid rash in sun-exposed areas, abdominal pain, nausea and vomiting(Ralston, Penman, Strachan, & Hobson, 2018).
Differential diagnosis:
1. Rheumatoid arthritis (ICD 10: M06.9.1): rheumatoid arthritis is an autoimmune condition.it is an inflammatory condition of the joints mainly in the hands and feet with symmetric involvement .it also presents with extraarticular manifestations like nodules on the skin, inflammation of the pericardium, pulmonary fibrosis and inflammation in the lungs(Smolen, Aletaha, & McInnes, 2016).
2. Mixed connective tissue disease (ICD 10: M35.9): mixed connective tissue disease is a rare autoimmune condition in which the body forms antibodies against its own healthy cells. This leads to symptoms like fever, joint pains, swollen hands and feet, pulmonary hypertension, Raynaud phenomenon(Gunnarsson, Hetlevik, Lilleby, Molberg, & rheumatology, 2016).
3. Rosacea (ICD 10: L71.9): Rosacea is a skin condition which is caused by a combination of factors including immune attack, genetics and environmental factors. It results in redness of the face with flushing or blushing, dry skin on the face with a feeling of burning sensation when exposed to the sun. the rash and redness on the face worsens with sun exposure. The patient also has a sensitive skin which reacts to most of the cosmetics (Gether, Overgaard, Egeberg, & Thyssen, 2018).
PLAN
The patient has systemic lupus erythematosus. She will have to undergo to specific diagnostic tests for confirmation of the disease and to determine the appropriate pharmacological and non-pharmacological treatments. The main goal is to suppress the immune attack on the cells of the body.
Labs and Diagnostic Tests:
· Full blood count to check for leukopenia and lymphopenia
· Antinuclear antibody test
· Anti-double stranded DNA test
· Anti-smooth muscle antibodies test
· Antiphospholipid antibodies
· The patient must have at least one of the clinical criteria and at least one of the immunologic criteria.
Pharmacological Treatment:
Glucocorticoids like prednisolone 5mg orally twice daily
Non-Pharmacological Treatment:
· Avoid sunlight exposure as much as possible.
· Use of sunscreen when going out at all times.
Education:
The monitoring of systemic lupus erythematosus is lifetime and the main aim for treatment will be to provide relief when there are flares and to prevent future flares as much as possible. The kidney function needs to be monitored keenly to avoid even worse complications.it may take long for the symptoms present now to completely resolve. The patient should be encouraged to maintain a healthy diet and exercise even more to avoid excessive weight gain and other complications that come with it.
Follow-ups:
Follow up appointment in two weeks to monitor the progress of the situation. In case of worsening symptoms, the patient should report to the hospital immediately. Referral to Rheumatologist for follow up in two weeks.
References
Gether, L., Overgaard, L., Egeberg, A., & Thyssen, J. J. B. J. o. D. (2018). Incidence and prevalence of rosacea: a systematic review and meta‐analysis. 179(2), 282-289.
Gunnarsson, R., Hetlevik, S. O., Lilleby, V., Molberg, Ø. J. B. p., & rheumatology, r. C. (2016). Mixed connective tissue disease. 30(1), 95-111.
Ralston, S. H., Penman, I., Strachan, M. W., & Hobson, R. (2018). Davidson's Principles and Practice of Medicine E-Book: Elsevier Health Sciences.
Smolen, J. S., Aletaha, D., & McInnes, I. B. J. T. L. (2016). Rheumatoid arthritis. 388(10055), 2023-2038.
