Past Medical History: The patient was born at term to a G1P1 mother by normal spontaneous vaginal delivery and had no prenatal or postnatal complications. Her growth and development were normal, with no surgeries or hospitalizations and no comorbidities. Her immunizations are up to date and she had chickenpox at three years of age.
Family Medical History: Significant for rheumatoid arthritis in paternal grandmother, hypothyroidism and migraine headaches in mother, and type II diabetes mellitus in maternal grandfather. No family history of childhood arthritis, lupus, cancer, irritable bowel disorder, psoriasis, or blood disorders.
Social History: The patient lives with her parents and her nine-year-old brother. Pets: one dog. The father is an engineer and the mother is a social worker who works part time. There is no smoking or firearms in home. The patient is in seventh grade and was doing well in school until the past six weeks.
On examination, the patient is alert and oriented to time, place, and person. Her short-term and long-term memory is grossly intact. Her blood pressure is 129/87, her heart rate is 100, her respiratory rate is 20, and her temperature is 36.80o C. Her height is 154.9 cm, her weight is 44.5 kg, and her body mass index (BMI) is 18.5. The head, eyes, ears, nose, and throat exam is remarkable for mild periorbital edema and a small ulcer on the hard palate. The fundoscopic exam is normal. Her skin is slightly pale, with erythematous maculopapular malar rash. There were mildly enlarged, nontender cervical and inguinal nodes. Her lungs are clear, and her heart is regular rate and rhythm with no murmurs or friction rubs. Her abdomen is soft and nontender with no mass or hepatosplenomegaly. Her breasts and pubic hair are early Tanner stage II.
Musculoskeletal exam: The patient’s gait is steady. She has good muscle strength in her upper and lower extremities, both proximally and distally. Her spine shows normal curvature and full range of motion. She has mild swelling and irritability in the right wrist and right 2nd and 3rd proximal interphalangeal joints. All other joints are unremarkable with full range of motion, and there is no evidence of active synovitis. All other deep tendon reflexes are normal.
Diagnoses:
- Proteinuria, anemia, rash, and positive ANA;
- Mild hypertension;
- Headaches and memory difficulties; and
- Probable systemic lupus erythematosus with lupus nephritis.
Plan: There is a lengthy discussion with the mother and patient regarding clinical findings, differential diagnoses, further diagnostic workup, and potential therapies.
