Client Complaints
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.
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.
Description of Client’s Support System
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.
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).
The patient’s health condition management will include education, collaboration facilitation, and medication (Buttaro et al., 2013). At that, the patient’s education and facilitation of her involvement in the treatment plan development are crucial for the optimal outcomes (McCance, Huether, Brashers, & Rote, 2013).
Patient’s education will include recommendations on the importance to stick to the care plan, follow directions closely, and being compliant with the office visiting plan since the problem may have a chronic character and require a considerable degree of cooperation between the patient and the health care provider (Buttaro et al., 2013). The ultimate goal of patient education is to help one lead a healthy life to boost immunity and strengthen the general resisting capacity of the body (Buttaro et al., 2013).
I will recommend the patient a healthy diet with a sufficient supply of vitamins and microelements such as calcium to support metabolism and the basic processes in the body. Also, the patient needs sufficient sleep and moderate to no alcohol consumption (Buttaro et al., 2013). I will recommend the patient total alcohol avoidance until she feels considerable improvements. Besides, she will need continuous control of blood pressure and weight. Further, physical activity is important but the client will need to avoid going out until the exacerbation stage passes. I would also suggest drug supplies for immune-boosting such as probiotics and vitamin-C-based drugs (Buttaro et al., 2013).
Medications will include hydroxychloroquine as the main agent (Buttaro et al., 2013). The patient will be recommended cyclophosphamide 60-120 mg per day and ibuprofen for inflammation and pain management each 6 to 8 hours for 7 days (Yu et al., 2014). Also, she will need to take prednisone 10 mg per day for 7 days (Buttaro et al., 2013).
Interdisciplinary collaboration
Since the client’s condition is associated with the other related problems, a visit to the interdisciplinary specialists will be recommended. Namely, the patient will need to visit an endocrinologist and rheumatologist (Buttaro et al., 2013.
Follow-up visit
The patient will come for a follow up in 2 weeks to assess the disease progression trajectory and evaluate the effectiveness of the offered disease management strategy.
References
Buttaro, T. M., Trybulski, J. A., Bailey, P. B., & Sandberg, J. (2013). Primary Care (4th ed.). New York, N. Y.: Elsevier.
CMS.gov (2014). ICD-9 Code Lookup. Web.
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2013). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MO: Mosby.
Yu, C., Gershwin, M. E., & Chang, C. (2014). Diagnostic criteria for systemic lupus erythematosus: a critical review. Journal of Autoimmunity, 48, 10-13.