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Lupus Treatment and Diagnosis Case Study

Patient B is a woman aged 20 years who resides in a big urban city. In October, the patient all of a sudden begins showing signs of fatigue, heart palpitations and anxiety. The woman recently sired her first child. She calls her doctor and explains her condition, but the physician tells her that the symptoms are arising from stress of giving birth. The physician recommends that the patient should get enough rest to overcome some of the complications.

The patient’s signs and symptoms become worse and then resolves gradually. The family members encourage her to strictly follow the physician’s advice and make the required efforts in reducing life stresses. After two years, the patient suffers from severe abdominal pain. Her clinician refers her to a more experienced internist in an advanced clinic for medical check-up. After the laboratory examination, the internist concludes that the patient’s gallbladder is the one causing all these complications. The internist advises the patient to take foods low in fat content and adopt healthy lifestyle practices such as regular physical exercise.

Five years later, patient B becomes pregnant this time round with the second child. The patient develops complications when her pregnancy is six months old. She shows signs of increased fatigue, headache, premature contractions and swelling of her legs. She contacts her physician who recommends bed rest forcing the woman to stay in bed for the last three months of her pregnancy. Immediately after the birth, patient B begins experiencing fresh symptoms. Swelling of knees and ankles and bilateral edema are some of the common signs she experienced. Besides, the patient experienced challenges in dancing and climbing a flight of steps.

During the winter period, the patient’s feet and hands become painful and discolored especially when exposed to cold temperatures. The woman visits her physician’s clinic who refers the patient to a more experienced rheumatologist to examine her condition. The rheumatologist conducts several medical examinations and runs numerous blood tests. Patient B’s results are as follows; positive ANA test at 1.640 and negative (normal) lupus erythematosus test/LE cell prep. Additionally, the patient has a negative rheumatoid arthritis factor (normal: negative with <60 U/Ml) and the sedimentation rate for the patient is 62 mm/hr. (normal: up to 20 mm/hr. for women).

The health specialist informs the woman that he is not quite sure of what she is suffering from but attributes her medical examination results to lupus. The rheumatologist prescribes a naproxen which is anti-inflammatory drug and advises patient B to go home and take a rest. However, the woman goes home frustrated become no medical practitioner has been able to establish her condition. Therefore, she goes home dissatisfied and begins to research on rheumatologic conditions. The woman began to suspect that she could be suffering from lupus based on the lab tests and the symptoms she was experiencing.

The patient made an appointment with a trustable rheumatologist in the city who examined the woman’s health status afresh. However, before beginning medical examination, the physician elicited the patient’s long medication history and enquired about the patient’s previous symptoms. The rheumatologist then subjects the patient to numerous medical examinations obtaining the results for anti-DNA antibody test, CBC, ANA, skin biopsy test of the lesions on the patient’s legs and complement series tests.

The results of skin biopsy showed signs of small vessel vasculitis. The anti-DNA test was elevated beyond the normal level. The red blood cell count was at 3.8 million/mm3 below the normal level which should range between 4.2-5.4 million/mm3 for a healthy person. The ANA results were 1.640 which is normal for a healthy person. The hematocrit was 35% which is below the normal requirements which holds in the range of 37% to 47% for women. The platelets were 138, 000/mm3 falling in the range of a healthy person which is 150, 000-400, 000/mm3. The hemoglobin was 10.5g/dL below the normal requirements which are 12-16 g/dL for women. Finally, the white blood cell count was 6, 000/mm3 falling in the range of a healthy human being which is 5, 000-10, 000/mm3 for women.

After the tests, the rheumatologist confirms that the patient that she is suffering from lupus. The physician therefore prescribes some medications to the patient. Some of the drugs prescribed include aspirin, acetaminophen, ibuprofen, and corticosteroids. Some of the nursing care plans implemented towards the treatment of the patient include impaired skin integrity and acute pain management. The care plans were selected based on the rationale experience of the client who manifested signs of swelling of feet, hands and abdominal pains. The interventions were found to be effective when evaluated against the current standard guidelines. The patient returns home feeling relieved because her condition has been established.



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