A flare to care

A Case Presentation
AI  female  GENERALIZED
27 y/o  single  Solsona  INC
BODY
th
WEAKNESS
6 admission
  intermittent fever with diaphoresis
Generalized body weakness
Diagnosed case of SLE
Dizziness
Mycophenolate
Knee pain mofetil 500 mg BID
2013  Easy
Prednisone
brusing30 mg OD
 malar
Caltraterash
plus 500 mg OD
 amennorhea
FeSO4 and folic acid OD, dosage unrecalled
alopecia

 Symptoms were recurrent

 Managed by rest & adherence to medications
INTERIM  Symptoms non-tolerable: Consult

 Generalized body weakness

 Managed by rest but still felt weak
2 weeks  No consultations
PTA
  Same symptoms still present
 Follow-up check-up at the OPD
4 days  CBC – low Hgb
PTA  Refused to be admitted

 Symptoms have not subsided yet

Few hours  Consulted  Admitted
PTA
 Past Medical History
(-) measles Childhood Surgical (-) history of surgeries
(-) chicken pox (-) accidents
(-) mumps (-) falls

(+) hypertension Medical Psychiatric

managed with Amlodipine 10mg OD denied any history
highest BP 210/110 of psychiatric illness
(-) diabetes mellitus, liver disease, asthma

Menarche: 14 y/o Obstetrics Allergies

(-) known allergies to
regular til 18 y/o food or medicines
without dysmenorrhea
Heredofamilial
(+) hypertension

Family
(-) kidney disease (-) stroke
(-) diabetes mellitus (-) thyroid & liver disease

History
(-) cancer (-) congenital disease (-) asthma
(-) SLE

Infectious
(-) TB (-) Hepatitis
 Personal History
 College Undergraduate
 Lives with her parents and 5 siblings
– with good interpersonal relationship
 Currently manages their own sari-sari store
 Non-smoker
 Non alcoholic beverage drinker
 Source of Stress prior to and during
appearance of symptoms – OJT (kitchen staff)
Review of Systems
General: + weight loss , no fever
Skin: no lumps, no sores, + change in color
Head: no headache, + dizziness, + lightheadedness
Eyes: + blurring of vision, no pain, no redness, no
excessive tearing
Ears: no hearing loss, no tinnitus, no vertigo, no
earaches, no discharges
Nose and Sinuses: no colds, no nasal stuffiness, no
discharge, no itching, no epistaxis
Mouth/Throat: no bleeding gums, no dentures, no
sore tongue, dry mouth, no sore throat, no
hoarseness; (+) oral ulcers
Neck: no swollen glands, no pain, no stiffness
Review of Systems
Breast: no lumps, no pain, no discharge
Cardiovascular: no chest pain, no palpitations
GI: no dysphagia, no heartburn, no poor
appetite, no nausea, no vomiting, no abdominal
pain, no pain on defecation, no diarrhea, no
constipation
Peripheral Vascular: no pain, no leg cramps, no
swelling
Urinary: no frequency, no urgency, no polyuria,
no nocturia, no pain, no incontinence, no
hesitancy, no dribbling, no hematuria, no flank
pain
Review of Systems
Musculoskeletal: no muscle pain, + joint pain,
no stiffness, no swelling, + paresthesia
Psychiatric: no nervousness, no tension, no
depression, no memory change
Neurologic: no mood changes, no slurring of
speech, no dizziness, no headache, no paralysis,
no numbness
Hematologic: + anemia, + easy bruising, no
bleeding, (+) previous blood transfusion
Endocrine: No heat intolerance, no cold
intolerance, no polyphagia, no polyuria, no
polydipsia, no increased sweating
 Physical
Examination

General Survey:
Awake, coherent, not in CP distress

Vital signs: Anthropometrics:

BP = 160/100 mmHg Height: 148 cm
T = 37.3 oC Weight: 45 kg
HR = 117 bpm BMI: 20.5 – Normal
RR = 18 cpm
O2 saturation = 99%, room air
 Physical
Examination

Skin, Nails: Fair complexion, with discoid rash on the

extensor surface of both arms, hematoma on left
anterior forearm, dry, smooth, with good skin turgor,
pale nail beds, palmar pallor, no pitting nails, no
clubbing of digits, CR of < 2 secs.
 Physical
Examination

HEENT:
Head: (+) Non-scarring alopecia, no mass, no tenderness
Eyes: Pale palpebral conjunctiva, anicteric sclera, no hemorrhage
Ears: No auricular tenderness; acuity good to whisper voice
Nose: Patent, pink nasal mucosa, septum in midline, no sinus tenderness
Mouth and throat: Dry pinkish lips; pinkish gums and buccal mucosa;
uvula in midline; tongue midline without fasciculation, no mouth
sores/ulcers, no gum bleeding, unenlarged tonsils, non-hyperemic, no
exudates
 Physical
Examination

Neck: no visible pulsations on carotid artery, no neck

vein distention, no CLAD, non-enlarged thyroid glands
no tenderness; no carotid thrills and bruits
Back, Thorax, Lungs: Symmetrical chest expansion. Resonant on
both lungs. Breath sounds heard on all lung fields. No crackles, no
wheezes noted.
Cardiovascular: Adynamic precordium, no heaves, no thrills, PMI
at 5th ICS MCL. Tachycardic, regular rhythm. No murmurs heard.
Abdomen: Globular, no visible pulsations, no visible blood vessels,
no bulging flanks, normoactive bowel sounds, tympanitic, no
palpable masses, soft non-tender, no CVA tenderness.
 Physical
Examination

Peripheral Vascular: radial, brachial,

popliteal, dorsalis pedis pulses all normal (+2)

Musculoskeletal:
Gait: normal
Arms: normal ROM
Limbs: normal ROM
Spine: No obvious deformities
 Physical
Examination

Neurological Examination
GCS: E4V5M6 (15)
Mental Status: Alert, cooperative
Cerebrum: oriented to time, place and person
Cranial nerves:
CN I = not assessed
CN II = pupils equally round reactive to light 2 mm, (+) ROR, intact visual acuity,
visual field full
CN III, IV, VI = EOM intact, no nystagmus
CN V = intact sensation, motor not tested
CN VII = no facial asymmetries, taste not assessed
CN VIII = intact gross hearing
CN IX, X = able to swallow without difficulty
CN XI = shrugs shoulder, turn head side to side
CN XII = tongue midline, no atrophy
 Physical
Examination

Motor: 5/5 on all extremities

Sensory: 5/5 on all extremities

Reflexes: not assessed

 Age
Gender: Female
Clinical
Manifestations
Environmental
Triggers

Salient Features
SYSTEMIC
LUPUS
ERYTHEMATOSUS, ACTIVE
Algorithm in the Diagnosis of SLE
 Skin (Acute, Subacute, Chronic Cutaneous LE) 

Oral Ulcer 
Systemic Lupus Alopecia 

International Synovitis 

Collaborating Clinic Renal (Prot/Cr ≥0.5, RBC casts, Biopsy) 

(SLICC) Criteria for Neurologic 

Classification of SLE Hemolytic anemia 

Leukopenia (<4000) or Lymphopenia (<1000)

Thrombocytopenia (<100,000)
In flare
but not in despair
ABELLON ▪ CASTILLO ▪EROJO ▪ LABASAN ▪ LORENZO ▪ ROLDAN