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Ihuman Case Week #9, Class 6550, for a 64-YEAR-OLD Female Patient. Reason for Visit Shortness of Br

HEAL100 Health Care — exam and revision material · Other

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Health Care exam material, 5 pages. Originally published on StudyMerit.

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5
Academic year
2025/2026
Language
English

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NURS 6550N 6550 Week 9 IHUMAN Patricia Doyle 21 y/o 5’6 112.0 lbs CC: fever and rash How can I help you today ? I haven’t been feeling great lately, I fell really tired. Ive had a rash on face x1 month, Fevreish. Hands and knees stiff and hurt. Any other symptoms we should discuss? Ya now my chests been hurting an five been feeling SOB. Eevnts around start of fever? I am not sure. All seems to have some after my trip to florida Events surrounding start of chest pain. The CP was last thing to start. Couple of days ago. At first rwally mild but now cannot ignore it. Rates 7/10. Worsened pain with deep inspritation. Alliviated with sitting up. Knee pain worse with bending or clombing stairs. 3/10 Hand apin worse with trying to grab glass or open door. Tylenol doesn’t do much. 3/10. Pain s ort of deep indside my small joints. Both hands equally. No changes in family Hx. No recent infection. Up to date with immunizations. Preforms breast exams. Takes Tylenol PE: Skin: Erythematous raised conlfueny rash over cheeks (malar distribution) and forehead; sparing of nasolabial folds. Similar rash to forearms and upper/anterior chest Hair: normal distribution and thickness Eyes: PERRLA Mouth: no oral mucosal lesions or tonsillar exudate Lymph nodes: bilateral distribution of palpable, small ( less than or equal to 1 cm), soft, mobile, nontender lymph nodes: cervical, axillary, inguinal Abdomen: active BS Extremities: erythematous, raised, confluent rash over forearms. Symmetric swelling and erythema of the metacarpophalanges and proximal interphalangeal joints. Bilateral anterior knee swelling. Symmetric edema and tenderness of the metacarpophalanges and proximal interphalangeal joint. Small bilateral knee effusions. Bilateral +1 pitting edema of the level of the knees. Range of motion. Reduced MCP’s, PIPs, and knees due to tenderness, not obstruction.

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Neuro. DTRs intact Musculoskeltal: good strength HPI: Patricia Doyle is a 21 y/o female who presents to the clinic today with complaints of fever and rash. She also has associated symptoms of fatigue, pain and stiffness to her hands and knees, shortness of breath and chest pain. She feels her symptoms began approximately 2 weeks ago after taking a vacation to Florida. She states her fever has been elevated to a little over 100 degrees that comes and goes. Her knee and hand pain is rated at a 3/10 and is worsened with movement such as climbing stairs or turning a door knob. She becomes short of breath with exertion and had an episode of increased shortness of breath with laughing. Her chest pain began last, couple of days ago, and has progressively worsened from mild to being unable to ignore. She rates her chest pain at a 7/10 that is worsened with deep inspiration and has some alleviation with sitting up. She has been taking Tylenol but has had minimal relief of her symptoms. Primary Diagnosis:  Systemic Lupus Erythematosus (SLE): Chronic inflammatory disorder characterized by autoantibody production responsible for antibody-mediated and immune complex deposition tissue damage (Ferri, 2019). Status/Condition: (Critical, Guarded, Stable, etc.)  Guarded Code Status:  Full Code Allergies:  NKDA Admit to Unit:  Med-Surg Unit Activity Level:  Up as tolerated Diet:  Regular Diet IVF  NS at 75 ml/hr Critical Drips :

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