Physical Assessment Case Study

A 35 year old female, Mary, works as an electrical engineer and presents to the office for evaluation of a new rash on her face. Mary states she has had the rash for about 1 week and denies using any new soaps, detergents, lotions, environmental toxins, medications, and foods that may cause an allergic reaction. The rash appears across her face and bridge of her nose. Mary states the rash appeared after she had spent a week hiking and camping in the Appalachian Mountains. She also states that the rash is itchy and painful. Mary denies trying anything to relieve the itch and pain. She states she has noticed the rash getting worse when she goes outdoors and says it has not spread to any other area of her body.
Mary states she has experienced additional symptoms of increased fatigue, fever, weight loss, mouth soreness, and muscle aches and pains that are worse in the hands and wrists. When questioned, Mary states she has not experienced any headaches, sore throats, ear pain, nasal or sinus congestion, chest pain, shortness of breath, cough, abdominal pain, temperature intolerance, polyuria, polydipsia, polyphagia, and pain with urination, constipation, or diarrhea. She also denies early morning joint stiffness or difficulty being able to ambulate in the morning.
Mary’s past surgical history includes a tonsillectomy at age 9 for chronic strep throat infections. However, since them, she has remained a healthy adult and has not been hospitalized. Her family history is positive for rheumatoid arthritis, as her mother suffers with the illness while she states her father is healthy.
Mary denies smoking tobacco and using illicit drugs. She does state she drinks a glass of wine almost every night with dinner. She has lived with her boyfriend for the past 5 years. She does not have any children.
Mary is alert and oriented and sits comfortably on the examination table. Her BP measures 112/66 mmHg, HR of 62 bpm and regular, RR of 12 breaths/min, and Temp of 100.3°F. The rash across her face is comprised of erythematous plagues over the cheek and bridge of her nose, sparing the nasolabial folds. Mary is normocephalic and atraumatic. Her sclera are white, the conjunctivae are clear, and the pupils constrict from 4 mm to 2 mm and are equal, round, and reactive to light and accommodation. Her oropharynx is moist with erythema present on the posterior pharyngeal wall. There is no presence of exudate and shallow ulcers appear in the buccal mucosa bilaterally. Her neck is supple without cervical lymphadenopathy or thyromegaly. She has a full range of motion with no swelling or deformity and her muscles have normal bulk and tone.
My initial suspicion is Systemic Lupus Erythematosus (SLE). There are two types of Lupus Erythematosus (McCance). The systemic type, the one I suspect, affects the whole body whereas the second type, Discoid Lupus Erythematosus only affects the skin. Lupus is an autoimmune disease that can cause havoc on multiple organ systems in the body. The body produces autoantibodies against nucleic acids, erythrocytes, coagulation proteins, phospholipids, lymphocytes, platelets, and other self-body cells. The autoantibodies create a complex with the cells they attack and circulate through the bloodstream. These complexes then become trapped within a vessel, obstructing blood flow to the nearby tissues and organ(s), causing further complications (McCance).
The most common clinical manifestation of Lupus is the butterfly rash across the bridge of the nose and onto both cheeks (McCance). Additionally, patients will also most likely experience symptoms of arthritis, renal disease, hematologic abnormalities, and cardiovascular diseases. To be positively diagnosed as having SLE, a patient must have at least four of the following conditions: facial rash, discoid rash, photosensitivity, oral or nasopharyngeal ulcers, nonerosive arthritis of at least two peripheral joints, serositis, renal disorder, neurologic disorders, hematologic disorders, immunologic disorders, and the presence of the antinuclear antibody (McCance). Mary is positive for the symptoms of the facial rash, generalized joint pain, pharyngeal ulcers, and photosensitivity. These symptoms are what indicate she may have SLE. Additionally, her mother has a history of an autoimmune disease, and Mary is more likely to develop SLE as she is a female between the ages of 20 and 40 years of age (McCance). To confirm the diagnosis of SLE, I would look to see if her doctor has ordered any blood work to test for the antinuclear antibody (McCance).
An accepted nursing diagnoses for Lupus is acute pain related to inflammation as evidenced by joint pain, fatigue, and mouth sores. As there is no cure for Lupus, the baseline health should be maintained, symptoms should be treated, and complications should be prevented. Clinicians will prescribe immunosuppressants to help depress the body from attacking itself (Ignatavicius). In the hospital, nurses administer these medications and educate the patient on why the drug has been prescribed, how to take the drug, and what possible side effects the patient may experience (Upchurch). In the office setting, a nurse would educate the patient on the medication and answer any questions the patient might have. In both settings, the nurse will also educate the patient on preventing infection because of the increased risk of developing an infection when on immunosuppressant drugs. Additionally, a symptom of the disease is photosensitivity. In all settings, the nurse would educate the patient on how to avoid the sun or if in the sun, protect their skin from further exacerbation of the illness. Lastly, nurses can help patients attempt to alleviate the joint pain and increase their energy levels to combat the fatigue. If the doctor has prescribed any pain medication, the nurse can go over the instructions and teach the patient how to safely take the medication. Nursing interventions to prevent pain include applying cold compresses, massage the affected area, and use pillows to support the joints. For increased energy, patients can make sure they get adequate rest at night, maintain a healthy, balanced diet, and engage in light exercises, as not to exacerbate the joint pain. Some factors have been identified that trigger the active stage of the condition and include sunlight, stress, pregnancy, and drugs. The patient should be advised to avoid these factors, if possible, especially the sunlight as previously mentioned (Upchurch).
Lastly, I would educate the patient on recognizing the signs of complications. For example, the immune complexes that are created as part of the disease process are especially attracted to the glomerular basement membrane of the kidneys (Ignatavicius). This complication puts the patient at risk for acute kidney injury and decreased renal perfusion. Signs of symptoms of a renal problem include decreased urinary output and flank pain in the area of the kidneys in the lower back. If the complication is addressed early in the injury, the injury can be reversed.

References

Ignatavicius, D. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.).
St. Louis, Missouri: Elsevier Saunders.
McCance, K., Huether, S., Brashers, V., & Rote, N. (2014). Pathophysiology: The biologic basis
for disease in adults & children (7th ed., p. 115, 130). St. Louis: Mosby.
Upchurch, S. (2014). HESI comprehensive review for the NCLEX-RN examination (Edition 4
ed.). St. Louis, Missouri: Elsevier.