Systemic Lupus Erythematosus and Its Symptoms Essay Assignment paper
Systemic Lupus Erythematosus and Its Symptoms Essay Assignment paper
The patient suffers from an itchy and painful rash on her face for one week. They are located across the client’s face and bridge of the nose.
HPI
The client is a woman of 35 years old. She states she had no such problem in the past. Currently, her main complaints are painful and itchy lesions, increased fatigue, fever, weight loss, and mouth sourness. The patient denies using any new detergents, lotions, foods, and medications. She noticed the problem first when she was on a camping tour in the Appalachians 1 week ago. The patient claims she did not use anything to try to remove the lesions. The problem tends to be worse when she goes outside. There is no rash spread in other areas according to the client. The patient claims she has no early morning joint stiffness, no nasal or sinus congestion, no sore throat, headache, chest pain, ear pain, cough, abdominal pain, temperature intolerance, shortness of breath, constipation, diarrhea, polyuria, polyphagia, polydipsia, and pain with urination. However, the patient complained of having increased muscle discomfort that is especially sensed in the wrist and hand. Systemic Lupus Erythematosus and Its Symptoms Essay
Systemic Lupus Erythematosus and Its Symptoms Essay Assignment paper
PMH
In the past, the client had no diagnostic and medications for this problem. The patient had tonsillectomy as a child of 9 years old. As an adult, she had no health issues and was never hospitalized.
Social/Personal History
The patient is an engineer with a master’s degree. She lives with her boyfriend for 5 years. The client has no children. She denies illicit drug use and smoking. She takes a glass of wine during her evening meal. The family history is characterized by the presence of rheumatoid arthritis in the mother, and the father is healthy.Systemic Lupus Erythematosus and Its Symptoms Essay
The patient has a support system that consists of her boyfriend.
Behavioral or Nonverbal Messages
The patient is alert and agile about the issues related to her health. She is eager to follow the recommendations.
Vital Signs including BMI
BP 112/66 mm Hg; HR 62 BPM and regular; respiratory rate 12 breaths/min; temperature 100.3°F;
Physical Assessment Findings
Erythematous plaques present in different areas on her face including the nose bridge; muscle with normal tonus; a full range of motion; no deformity or swelling; normocephalic; atraumatic; white sclera; clear conjunctivae, constrict pupils of 2 to 4 mm, equal, round, and reactive to light and accommodation; supple neck; no cervical lymphadenopathy or thyromegaly; shallow ulcers in the buccal mucosa bilaterally; no exudates; and oropharynx moist with erythema in the posterior pharyngeal wall.Systemic Lupus Erythematosus and Its Symptoms Essay
Diagnoses/Client Problems
M32.9 Systemic lupus erythematosus (SLE) unspecified (CMS.gov, 2014).
Care Plan
The patient suffers from fever, itchy, and painful erythematous plaques present both around the face and at the nose bridge, pains in muscles, and has a family history of rheumatoid arthritis. All these factors suggest the presence of SLE (Buttaro, Trybulski, Bailey, & Sandberg, 2013; Yu, Gershwin, & Chang, 2014).
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