TASK – 64    

Patient’s name:         Mrs. Rose Debham

Date of Birth: 4th July, 1989  

Social History:         

recently married, no smoking or alcohol drinking

Past Medical History:          

previously fit, Migraine diag 5 months ago – another GP

Medication History:  Aspirin & Codeine & Metoclopramide to control migraine

Family history:          mother- hypothyroidism

2/12/2009 Subjective: feeling unwell for 3 months, intermittent fevers and sweats, anorexia Joints & muscles- ache, hands- painful & clumsy with stiffness in mornings for about 1 hour

Objective: looks flushed, Temperature 38.6 degree C, Facial oedema – present, pulse rate- 95/ min, BP- 110/65, Multiple aphthous-like ulcers on buccal mucosa, heart & lungs – normal, spleen – enlarged, hand joints swollen and tender.

Assessment: possibility of autoimmune disease or infections

Plan: Explain the possibilities, confirmatory tests such as urinalysis, blood tests, ESR, C reactive protein, blood culture, antibodies screening, Ibuprofen 400 mg 3 times daily for symptomatic control, review in a week’s time

10/12/2009. Subjective: noticed slight improvement but still has pain in hand joints, no fever, concerned about serious complications of autoimmune diseases

Objective: swelling in hand joints -reduced, temp- normal, urinalysis-trace of protein (0.3g/L), complete blood examination – haemolysis & pancytopenia, ESR- 55mm/hour, C reactive protein – 5 mg/L, Blood Culture – Negative, X ray (hand joints ) – soft tissue swelling & no erosion, CXR- normal, Antinuclear & double stranded DNA antibodies- positive.

Assessment: Systemic lupus erythematosus

Plan: general measures (exercise, avoidance off UV light, screen), continue NSAID (Non-Steroidal Anti-Inflammatory Drug), hydroxycloroquine 200 mg 2 times daily, refer to specialist to assess systemic involvements, regular reviews every month

20/1/2010. Subjective: regular check-up, all symptoms under control, able to cope normal daily activities, arthritis, fever & lethargy -well managed with current medication expressed a strong desire to conceive in near future, use condoms & spermicide for contraception

Objective: all examinations – unremarkable            

Assessment: well-controlled SLE

Plan: Continue current medication to prevent recurrence, Explain the risks to mother & fetus, refer to consultant obstetrician for advice prior to conception

Writing Task: Using the information in the case notes, write a letter of referral to Dr. Stephanie Coleman, Consultant Obstetrician at the Royal Adelaide Hospital, North Terrace, Adelaide SA 5000.

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