Female who presents with a “butterfly rash” on her had ...

[Pages:10]Kallendorf-SOAP #2 note

S: (Subjective data)

P.B. Pt number 291 21 year old Caucasian female

CC

" I have a butterfly rash on my face"

HPI P.B. is a 21 year old healthy adult Caucasian female who presents with a "butterfly rash" on her face that has been present for one week. The rash is sensitive to light, but does not itch. She reported this rash to her PCP and was given a 3 days prescription for Prednisone taper which she completed yesterday. She says she took this as prescribed and had no results. She also reports that she has had moments that have "taken her breath away" and she feels like her heart is racing when this happens. She has been tired and her fatigue has gotten worse in the last week. She also reports that she has had headaches, joint pain, and swelling in her feet at the end of the day. She has had these symptoms every day for the last week and a half. She has also had an intermittent fever of 99.0. She has not taken any other medications except for the Prednisone for these symptoms. She was started on Lexapro 10mg 1 month ago and takes her medication daily. She started this medication after reporting that she was feeling anxious and depressed with recurrent episode of shortness of breath and feeling "panicky". She reports an improvement in her depression and anxiety, but she still has "the breathing problem" that causes her concern. She denies that this shortness of breath is exacerbated or relieved by anything. She cannot gauge when an episode is about to occur and it last just moments, but it happens 6-10 times a day.

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She reports that her maternal grandmother and two maternal aunts have lupus and she has looked up her symptoms on Web MD and "they all fit". She would like to get tested for this. She denies ever being bit by a tick, having any sick contacts, or having any sore throat.

PMH

P.B is an active young adult. She exercises at least 3 times a week for a minimum of 30 minutes. She reports herself to be in good health. She has no history of major problems. Her history does include:

Immunizations for age: o UTD on the following: She had these vaccines completed prior to entering college at age 19 Tdap Varicella HPV-3 dose MMR Meningococcal o Vaccine needed today Influenza, she has refused this and reports that she will get this from her employer for this flu season.

Seasonal allergies: Stable with below treatment o Cetirizine 10mg each morning o Singulair 10mg each night o Flonase 1 spray to each nostril daily

Depression and anxiety: Improved with below treatment o Lexapro 10mg daily

Screenings

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Last eye exam: September, 2015. No change in vision since previous exam and she does not require corrective lenses.

Last dental exam: May, 2015. No dental carries, no loose teeth. Pt has all lower adult teeth with bridge on bottom. Next appointment is scheduled for next month.

Pap smear and Breast exam: She sees a gynecologist and has had an exam Jan 2015. Her results were normal. She is sexually active in a monogamous relationship. She reports that she completes her SBE monthly after her cycle which is regular every 28 days.

PSH

Tonsillectomy o August 27, 1998; 4 years old

Current medications

Lexapro 10mg 1 tablet daily Levora-28: 0.15-0.03 1 tablet daily Cetirizine 10mg each morning Singulair 10mg each night Flonase 1 spray to each nostril daily Allergies Latex

o Hives, Itching Sulfonamides

o Rash, Hives, Itching Seasonal allergies, no specific allergy tested has been completed

FH

Mother living at 43. Alive and well. Depression.

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Father living at 44. Alive and well. HTN Brother living at 25. Alive and well, no known health concerns Maternal grandmother living 71. Dyslipidemia, HTN, Lupus Maternal Aunt x 2 Lupus. Ages and other conditions unknown.

SH

Denies tobacco use, alcohol intake, or illegal drug use. Enrolled in community college courses Monday, Wednesday, and Friday. In a relationship for the last 18 months with the same person. Small close knit group of friends. Strong support system with close immediate and extended family. Works Tuesday, Thursday, and every other weekend in a local pharmacy as a technician. Uses Blue Cross Blue Shield for insurance with prescription drug coverage. Strong support system with close immediate and extended family.

ROS

General appearance: this is a well-developed, well nourished, Caucasian female who appears to be in no distress.

Skin: admit butterfly rash sensitive to light. Denies lesion, itching, hives, edema, or dryness. Head: unremarkable is normocephalic, with no bruising noted. Eyes: negative for itching, redness, swelling, discharge, photo phobia, visual loss. Ears: negative for ear pressure, pain, discharge, hearing loss. Nose: negative for nasal discharge, nasal congestion, sinus pain, nose bleed, sneezing, post nasal

drip. Mouth and throat: negative for difficulty swallowing, hoarseness, mouth ulcers. Neck: negative for enlarged lymph nodes, pain, stiff neck, swelling.

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Respiratory: Admits intermittent dyspnea. Denies cough, wheezing, tachypnea. Cardiovascular/Peripheral Vascular: Admits tachycardia, bilateral lower extremity edema. Denies

cyanosis, swelling, erythema of skin. Gastrointestinal: Negative for abdominal pain, nausea, vomiting, constipation, diarrhea Urinary: Negative for blood and urine, dysuria, urgency, frequency Musculoskeletal: Admits polyarthralgia. Denies weakness. Psychiatric: Admits anxiety, depression. Denies agitation, mood swings, insomnia, suicidal

thoughts Neurological: negative for weakness, loss of consciousness, unsteady gait, paralysis, and tremor. Hematologic: Negative for easy bruising or bleeding. Endocrine: Admits fatigue and weight gain. Denies heat or cold intolerance, excessive sweating,

excessive thirst or hunger, polyuria. O: Objective

General Appearance: this is a well-developed, well nourished, Caucasian female who is currently appears to be in no distress.

Vital Signs: temp 97.9, respirations 18, blood pressure 118/60, heart rate 67 o Ht 5 ` 5" o Wt 151 lbs. o BMI 25.13

Full Physical Exam o Head: unremarkable, normocephalic, with no bruising noted. o Eyes: Pupils are equal round and reactive to light. Sclera white, extra ocular movements intact. No hemorrhage or exudate noted.

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o Ears: clear external auditory canals, pinnae normal shape, no pre-auricular pits or skin tags. TM's visualized, pink-grey bilaterally with no bulging noted. No erythema or discharge.

o Nose: nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge

o Mouth/Throat: buccal mucosa moist, positive gag reflex. Oropharynx w/ no signs of erythema or ulceration. Normal movement of soft palate.

o Neck: Supple with no lymphadenopathy. Trachea midline with full ROM. No JVD is appreciated. Thyroid gland size normal, non-tender, no nodules or masses present on palpation.

o CV: regular rate and rhythm, S1 and S2 were heard with no rubs, murmurs, or gallops. No S3 or S4 noted. Normal apical impulse.

o Pulmonary: Lungs clear to auscultation bilaterally. Patient is breathing comfortably on room air.

o Gastrointestinal: abdomen soft, non-tender, non-distended, bowel sounds are present in all four quadrants. No organomegaly is palpated. Liver non-tender to palpation

o Extremities: no clubbing or cyanosis and noted. Bilateral lower extremities with no edema. Plus two pedal pulses noted bilaterally. Calves supple none tender.

o Neurologic: patient in awake and alert with no focal deficit. Moves all extremities symmetrically with appropriate tone; DTRs with negative tremor/clonus; positive sensation.

o Psychiatric: Mood and affect appropriate. Well-adjusted and comfortable during exam. Judgement and insight intact.

o Skin: warm, dry, intact. Butterfly rash present. No lesions or unusual bruising. o Musculoskeletal: Symmetrical with full ROM. Strength 5/5 in all extremities. Negative

kyphosis, lordosis, joint swelling

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o Motor: good muscle tone. Appropriate fine and gross motor skills.

Diagnostic Testing:

ANA o Suggests SLE

ESR o Suggests SLE if elevated or perhaps infection

C-reactive protein o Suggests inflammatory process

CBC with diff o To determine if there is an underlying infection or if levels are lower than expected may suggest SLE

BUN/Creatinine o To assess kidney function. Would expect these numbers to be elevated if kidney issues are present.

ELISA o Suggestive of SLE

Rheumatoid factor o To determine if patient has developed RA

IgG antibody o To assess for Lyme disease.

Urinalysis o To assess for proteinuria

Lipid panel o To assess health maintenance

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A: Assessment Level of Visit: 92214 Differential Diagnosis:

Systemic Lupus Erythematous (695.4) o Supported by malar rash with photosensitivity, anxiety, episodes of dyspnea and tachycardia, joint pain, fatigue o Refuted by absence of oral ulcers

Lyme Disease (088.81) o Supported by joint pain, dyspnea, fatigue o Refuted by negative neurological findings, swollen joints, malar rash

Rheumatoid arthritis (714.0) o Supported by joint pain, fever, fatigue o Refuted by negative swollen joints, hand/foot joint pain, malar rash

Generalized anxiety disorder (300.2) o Supported by previous diagnosis, anxiety, dyspnea, tachycardia o Refuted by low grade fevers, joint pain, malar rash

Problem list: Butterfly rash o 782.1 Joint pain o 719.40

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