Case 5. Fever (Systemic lupus erythematosus)
Author: Galyna Bilyk
Case outline
You are a young family doctor in polyclinic. Patient Maria Kosovan,
35 years old, looks a little tired, lofty. Mary complains of general
weakness, rapid fatigability, periodic fever (37.0-37.2 C), anxiety,
palpitations, periodic pain in small joints of the hands, swelling,
frequent irritation. These symptoms began to notice about 3 months ago.
Transmitted diseases - frequent catarrhal diseases, chronic noncalculous
cholecystitis, menstruation from 13 years, sexual life from 20 years.
No allergies were observed. Social history: married, working as a nurse
for 12 years, no harmful habits, currently 6 months breastfeeding baby.
Life history: 3 pregnancies, two of which ended in childbirth. First
pregnancy without features, childbirth physiological, no complications,
older daughter 5 years. 2nd pregnancy due to the developmental defects
of the fetal egg ended up scratching for gestation for about 3-4 weeks 2
years ago. 3rd (delivery 6 months ago) complicated by the threat of
interruption. The child was born in the gestation period of 39 weeks by
means of a caesarean section. Written home on the 5th day after
childbirth. Review: Temperature - 36.9 C, heart rate - 79 beats / min,
BH - 20 / min, AP - 130/80.
Choices are denoted Excellent (E) / Good (G) / Poor (P)
Choice 1. To send for inspection and
treatment in a hospital (G). Continue the examination and examination of
the patient (E). Send home with a request to apply for examination in
case of deterioration (P). Refer to the neurologist for review (G).
At the doctor after 4 months. After your last meeting, she started
taking nimesil (1 sachet 2 times a day) and her condition improved;joint
pain decreased, she was easier to do her homework. However, gradually
the previous complaints returned and even intensified. There are
volatile, unstable and short-term pains in the joints of the hands and
feet, increased mucosal weakness, occasional uncomplicated pain in the
upper abdomen is observed. A month ago Maria independently turned to the
gastroenterologist who examined her, conducted an ultrasound
examination and explained that the cause of periodic pain is more likely
to be dyskinesia of the biliary tract. She was prescribed a low-fat
diet and recommended a healthy lifestyle, including an increase in
physical activity. She also notes that this winter began to feel low
temperature intolerance, although she never loved cold weather, but
suddenly she had a problem when her arms and legs became painful and
there was a pallor of the skin of these areas. in the cold.
Choice 2. Biochemical blood test,
rheumatologic tests, consultation of infectionist (E) Biochemical blood
test, x-ray bristles, orthopedic consultation (G) Biochemical blood
test, ultrasound examination, surgeon consultation (P).
In the hospital. You are a doctor of the pulmonary department.
Objectively: the temperature is 38.2С, the breathing is 26-28 / min, the
heart rate is 90-92 / min. Skin and visible mucous membranes are pale,
dry, cheilitis on the lower lip. It was unheated, in the oral cavity in
the cheek area, isolated minor small ulcers up to 3-4 mm. Neck and
axillary lymph nodes are slightly enlarged, elastic, motile, moving,
spherical, symmetrical, painless in palpation, small joints of the upper
and lower extremities, slightly swollen, painful in palpation, mucosal
tone and muscle strength are preserved, with palpation of mucous
membranes there is an insignificant pain. On the upper and lower
extremities there are redness areas with whitish-gray scales in the
center, areas of scar atrophy, surrounded by a zone of hyperkeratosis
and hyperemia along the rim, deformation of the nails.
Heart tones are rhythmic, weakening of the 1st and 2nd tones, systolic noise on the apex.
Choice 3. General blood test, general
urinalysis, ECG (P), general blood test, chest x-ray, ECG (E), general
blood test, EchoCG, ultrasound examination of pulmonary sinus (G)
Doctors suspected diagnosis of systemic lupus erythematosus
Learning outcome for VP case
- The syndrome of fever of unknown origin, infectious rash, clinical manifestations.
- Leading clinical symptoms and syndromes in systemic lupus erythematosus.
- Clinical course and complications variants.
- Laboratory and instrumental datas.
- Differential diagnosis of systemic connective tissue diseases.
- Treatment and clinical management of patients.
- Preventing complications.
Medical error
- insuffience skills;
- bravado;
- poor team working;
- playing the odds.
