Chief Complaint n “ I am short winded and tired. Also when I eat it feels like the food sits in my chest.”
History of Present Illness n 60-yo African American female presents with a history of severe fatigue, dyspnea, and dysphagia. Fatigue has developed over past 6 months and is worse upon exertion. Dysphagia is to both solids and liquids.Admits to a 60 lb weight loss and feeling “dizzy” on occasion. Also admits to episodes of constipation and alternating diarrhea. Denies chest pain, syncope, blood per rectum or other GI complaints.
Past Medical History n Currently being followed by SLE clinic for presumptive Dx of SLE (Connective Tissue Disorder Workup) n Pericardial Effusion - 9/13/00. Treated by pericardial window. n Hysterectomy 1988 - Dysfunctional Uterine Bleeding n Right Breast Lumpectomy 1987 - benign n Blood Transfusion - 1987 n Chronic Anemia - Diagnosed 1987 n History of Hypertension - Treated with Lasix 40mg/day/P.O.
Past Medical History Continued n Allergies - PCN n Meds - Lasix 40 mg P.O. q day, Naproxen 250mg P.O. BID n Social Hx - Noncontributory n Fam Hx - Brother with MI, HTN; daughter RA since age 2
ROS n General - easy fatigability n Hematopoetic - chronic anemia, Hx of transfusions, Denies bleeding per rectum n Other ROS noncontributory
Physical Examination n General - 60 yo African American female who looks older than stated age. Cachectic appearance, lethargic though in no apparent distress. AO x 3 n Vitals - P: 72/min, T: 97.1, RR: 18/min, BP 120/70 supine and 115/65 sitting. n HEENT - Inc. JVD, no lymph nodes
Physical Examination Con’t n Chest - No wheezes or rales, decreased breath sounds L base n Cardiac - s1, s2 normal; no audible murmur n Abdomen - LLQ tenderness, no palpable masses n Rectal - negative guaiac n Ext - no edema
Labs (Abnormals) n K - 7.4(hemolyzed), BUN - 45, Creat - 1.7 n Hgb - 7.5, Hct - 24.1, MCV 89, ESR - 120 n FANA +, ANA 640 n CXR - borderline cardiomegaly with left pleural effusion n EKG - sinus bradycrdia 52/min
Impressions n Anemia (chronic) - rule out iron deficiency anemia due to blood loss, connective tissue chronic disease anemia, hemolysis n Pericardial Effusion by Hx - rule out malignancy, pericarditis, uremia n Prerenal Azotemia - volume depletion, cardiac insufficiency, liver disease n Dysphagia - rule out esophageal malignancy, achalasia, nutcracker esophagus n Connective Tissue Disorder - SLE
SLE n Chose to speak about SLE as it can cause many of the symptoms this patient is experiencing n Occurs at any age and ranges from mild dermatologic and joint symptoms to organ failure n More common in women and most severe in blacks and hispanics
Etiololgy n Unknown but immune complex formation support an immunologic origin
Clinical Manifestations n Any organ system n Systemic - malaise/fatigue n Vascular - Raynaud’s phenomenon n Renal - proteinuria, lupus nephritis, glomerular destruction n Pulmonary - pulmonary hemorrhage n Cardiac - pericarditis n Hematologic - anemia both hemolytic and non-hemolytic
Diagnosis n Clinical as no one test or feature is fully diagnostic n Antinuclear antibodies
Treatment n No cure has been found n Immunosuppresive agents n NSAIDs n Corticosteroids