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Chief Complaint
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I am short winded and tired. Also when I eat it feels like the food sits in my chest.
60-yo African American female presents with a history of severe fatigue, dyspnea, and dysphagia. Fatigue has developed over past 6 months and is worse upon exertion. Dysphagia is to both solids and liquids.Admits to a 60 lb weight loss and feeling dizzy on occasion. Also admits to episodes of constipation and alternating diarrhea. Denies chest pain, syncope, blood per rectum or other GI complaints.
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Currently being followed by SLE clinic for presumptive Dx of SLE (Connective Tissue Disorder Workup) Pericardial Effusion - 9/13/00. Treated by pericardial window. Hysterectomy 1988 - Dysfunctional Uterine Bleeding Right Breast Lumpectomy 1987 - benign Blood Transfusion - 1987 Chronic Anemia - Diagnosed 1987 History of Hypertension - Treated with Lasix 40mg/day/P.O.
ROS
General - easy fatigability s Hematopoetic - chronic anemia, Hx of transfusions, Denies bleeding per rectum s Other ROS noncontributory
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Physical Examination
General - 60 yo African American female who looks older than stated age. Cachectic appearance, lethargic though in no apparent distress. AO x 3 s Vitals - P: 72/min, T: 97.1, RR: 18/min, BP 120/70 supine and 115/65 sitting. s HEENT - Inc. JVD, no lymph nodes
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Labs (Abnormals)
K - 7.4(hemolyzed), BUN - 45, Creat 1.7 s Hgb - 7.5, Hct - 24.1, MCV 89, ESR -120 s FANA +, ANA 640 s CXR - borderline cardiomegaly with left pleural effusion s EKG - sinus bradycrdia 52/min
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Impressions
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Anemia (chronic) - rule out iron deficiency anemia due to blood loss, connective tissue chronic disease anemia, hemolysis Pericardial Effusion by Hx - rule out malignancy, pericarditis, uremia Prerenal Azotemia - volume depletion, cardiac insufficiency, liver disease Dysphagia - rule out esophageal malignancy, achalasia, nutcracker esophagus Connective Tissue Disorder - SLE
SLE
Chose to speak about SLE as it can cause many of the symptoms this patient is experiencing s Occurs at any age and ranges from mild dermatologic and joint symptoms to organ failure s More common in women and most severe in blacks and hispanics
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Etiololgy
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Clinical Manifestations
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Any organ system Systemic - malaise/fatigue Vascular - Raynauds phenomenon Renal - proteinuria, lupus nephritis, glomerular destruction Pulmonary - pulmonary hemorrhage Cardiac - pericarditis Hematologic - anemia both hemolytic and non-hemolytic
Diagnosis
Clinical as no one test or feature is fully diagnostic s Antinuclear antibodies
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Treatment
No cure has been found s Immunosuppresive agents s NSAIDs s Corticosteroids
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