History
A 25-year-old female patient is seen in the office after her primary care physician requested a consultation for a possible diagnosis of systemic lupus erythematosus (SLE). The patient presents today with muscle pain in both legs, she rates the pain at an 8 on a scale of 10. She states she experiences throbbing, usually at the end of the day, which lasts for one to two hours. She complains of hair loss and experiences constant fatigue, even when she gets the proper amount of sleep. She has developed a rash on her cheeks and her right arm, and the rash worsens with exposure to the sun. The patient reports that the symptoms began approximately six months before. She takes ibuprofen to ease muscle pain. She denies joint pain or swelling, eye problems, chest pain, respiratory symptoms or gastrointestinal or genitourinary problems. She has not had an infection and has not traveled recently. She denies smoking and drinking alcohol. Family history is negative for systemic inflammatory diseases. Her mother has hypertension, and her father has diabetes.
Past History
She had chicken pox and measles as a child. She works full time as a dock worker.
Examination
The patient is alert. Her height is 5’5”, weight is 130 lbs., and her blood pressure is 115/80. Her heart rate is fast and regular at 125 beats/minute. Her respiratory rate is eight to nine breaths per minute. Her hair is thin. She has a malar rash, and the rash on her right arm has patchy redness. Her mouth has sores on the inside of her cheeks. Her lungs are clear; her heart has no murmurs, gallops or rubs. Her chest is not tender to palpation. Her abdomen is soft, nontender, with no masses or HSM. Her gait is stiff. Neurologic exam shows normal sensory exam and reflexes. All joints are normal. There is bilateral warmth, swelling and tenderness in her thigh muscles. She is also tender over her left tibia.
Assessment & Plan
Orders were written for an electrocardiogram, CBC, ANA, antiDNA, CK, urinalysis, TSH, serum creatinine, chemistries and LFTs.
The patient was prescribed 500 mg of chlorzoxazone up to three times a day for the muscle pain. She was counseled not to drive or consume alcohol when taking this medication and that she may wish to take it only when she returned home from work at the end of the day. She was scheduled to return to the office in two weeks.
A written consultation letter was sent to her primary care physician concerning her possible diagnosis of SLE and the tests ordered to assess other possible causes of her symptoms. Lab test reports will be sent to her primary care physician when available.
Diagnosis
Muscle pain, rash, fatigue, hair loss, mouth sores, tachycardia: Possible SLE.
