Luisa, 16 y/o, female Diagnosed with SLE at 12 Prolonged fever Malar rash Photosensitivity Hair loss Oral ulcers Easy fatigability Anemia Neutropenia Thrombocytopenia (+) ANA (+) anti-dsDNA
In January 2009…. Pain on the L knee with swelling after a fall With fever and chills Self-medicated with Ibuprofen for 2 weeks, no improvement
PE Findings Ill-looking Wheelchair borne BP: 110/70 CR: 102/min RR: 24/min Temp: 39.8°C No rash or oral lesions Regular heart rate and rhythm No murmur or rub Regular heart rate and rhythm No murmur or rub Clear breath sounds Soft non-tender abdomen, no hepatosplenomegaly L knee – warm tender and swollen w/ limited ROM
presence of four or more of the following 11 criteria, serially or simultaneously, during any period of observation 1.Malar rash 2.Discoid rash 3.Photosensitivity 4.Oral ulcers 5.Arthritis (non-erosive) 6.Serositis (Pleuritis or Pericarditis) 7.Renal disorder persistent proteinuria > 500 mg per 24 hours (0.5 g per day) or > 3+ cellular casts 8.Neurologic disorder 9.Hematologic disorder hemolytic anemia with reticulocytosis leukopenia, < 4,000 per mm3 (4.0 _ 109 per L) on two or more occasions lymphopenia, < 1,500 per mm3 (1.5 _ 109 per L) on two or more occasions thrombocytopenia, < 100 _ 103 per mm3 (100 _ 109 per L) in the absence of offending drugs 10.Immunologic disorder 11.Antinuclear antibodies
In the patient… Malar rash Photosensitivity Oral ulcers Anemia Thrombocytopenia (+) ANA (+) anti-dsDNA L knee – warm tender and swollen w/ limited ROM
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