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BIOETHICS SLE in Pregnancy SAN GABRIEL, SANIANO, SORREDA

BIOETHICS SLE in Pregnancy SAN GABRIEL, SANIANO, SORREDA. Patient Information. The patient is EG, a 21 year old female, who came in for chief complaint of seizures. The patient is a diagnosed case of Systemic L upus Erythematosus since December of 2008. Initial Presentation.

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BIOETHICS SLE in Pregnancy SAN GABRIEL, SANIANO, SORREDA

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  1. BIOETHICS SLE in Pregnancy SAN GABRIEL, SANIANO, SORREDA

  2. Patient Information The patient is EG, a 21 year old female, who came in for chief complaint of seizures. The patient is a diagnosed case of Systemic Lupus Erythematosus since December of 2008.

  3. Initial Presentation • Initially presented with: • malarrash • photosensitivity • arthralgia • hair loss and • oral ulcers • edema of both lower and upper extremities weakness • ANA positive

  4. Systemic Lupus Erythematosus • Initially presented with: • malarrash • photosensitivity • arthralgia • hair loss and • oral ulcers • edema of both lower and upper extremities weakness • ANA positive

  5. Medications Regular Follow-up Prednisone 10 mg once a day Hydrochloroquine 200 mg once a day Rheumatology Family Medicine

  6. Systemic Lupus Erythematosus Follow-up Pregnancy Uterine 14 1/7 weeks AOG G1P0 PGH Obstetrics High Risk Clinic Last Follow-up: February 17, 2010

  7. History of Present Illness • 2 WEEKS PTA • (+) decreased appetite • (+) gradually increasing generalized body weakness • (-) interventions or consults

  8. History of Present Illness • 4 DAYS PTA • generalized weakness now more prominent on both right upper and lower extremities • (+) behavioral change • (+) general decrease in activity • (+) episodes of staring blankly into space • (+) cough productive of whitish phlegm • (+) febrile episodes (qualitative) • (-) nasal congestion

  9. History of Present Illness • 2 HOURS PTA • (-) rousability • (+) seizure - upward rolling of the eyeballs, grinding of teeth and clenched fists (duration ~5 minutes) • -> Promptly rushed to PGH, hence this admission

  10. Review of Systems • General • (+) fever, (-) nausea and vomiting, (+) weakness, (+) weight loss • Integumentary • (+) malar rash, (-) discoid rash,(-) hairloss • Eyes • (–) blurring of vision • Ears • (–) loss of hearing, tinnitus • Nervous • (–) dysphagia, dysphonia, seizures, dizziness, (+) headache prior

  11. Review of Systems • Respiratory • (+) cough, (+) exertionaldyspnea, (-) colds • Circulatory • (–) chest pain, (-) bleeding • Digestive • (-) melena, (-) constipation, (-) diarrhea, (-) abdominal pain • Urinary/ Reproductive System • (-) urinary incontinence, (-) polyuria/nocturia, dysuria(-) dribbling, (-) tea colored urine, • (+) vaginal spotting (Feb 14, 2010)

  12. Past Medical History (+) SLE, 2008 (-) HPN, DM, goiter, BA, PTB, CA (-) heart problems (-) allergy

  13. Family Medical History Personal and Social History (-) SLE, HPN, DM, goiter, BA, Ca, heart problems Pt lives with live-in partner, a college graduate (BA HRM), currently unemployed. Non-smoker, occasional alcoholic beverage drinker. (-) known exposure to chemicals, and radiation

  14. Obstetric History G1P0 LMP: October 9, 2009 , PU 14 1/7 weeks AOG by late ultrasound

  15. Physical Examination Patient is awake, with regard, responds to name calling, inconsistently follows commands, with no verbal output HR: 142 bpm BP: 100-110/60-70 mmHg RR: 40 T: 38°C

  16. Physical Examination HEENT: (+) slight exophthalmos, anictericsclerae, pink palpebral conjunctivae, (-) TPC, ANM, (-) NVE, (-) CLAD Chest/Lungs: equal chest expansion, (+) bibasal and mid-field rhonchi, both lung fields ECE, (+) bibasal and mid-field rhonchi, both lung fields CVS: adynamicprecordium, distinct heart sounds, tachycardic, regular rhythm, (-) murmurs

  17. Physical Examination Abdomen: flat, normoactive bowel sounds, soft, (-) masses, (-) tenderness, liver edge not palpable Genitourinary: deferred Extremities: full and equal pulses, pink nailbeds, (-) edema/cyanosis, (+) blanching erythematous rash over extremities

  18. Neurologic Examination • Pt is awake, with regard, responds to name calling, inconsistently follows commands, with no verbal output, uncooperative. • I – not assessed • II – pupils 2/2 EBRTL, primary gaze midline, (-) preferential gaze • III, IV, VI – (+) slight LR palsy, R; (+) visual threat, B • V – brisk corneals • VII – (-) facial assymetry • VIII – gross hearing intact • IX, X – good gag and swallow • XII – refuses to protrude tongue • With spontaneous, purposeful movement of the extremities. • Withdraws to pain, bilateral extremities • (-) Babinski • (-) clonus • patient resists neck flexion. • (-)dysmetria/dysdiadochokinesia • (-) nystagmus • Motor Strength: 3/5 on all extremities • Sensory: WTP on all extremities

  19. Laboratories CBC (2/28)

  20. Laboratories Electrolytes (2/28)

  21. Laboratories ABG (2/28)

  22. Laboratories Urinalysis (2/28)

  23. Laboratories PT/PTT (2/28)

  24. Laboratories • ECG • 2/28: sinus tachycardia, normal axis, low voltage complexes • 3/11: sinus tachycardia, normal axis, low voltage complexes • 3/12: sinus tachycardia, normal axis, low voltage complexes • 2D Echo • concentric LVH with good wall motion and contractility, EF=73% minimal pericardial effusion, mild pulmo HPN, incidental finding of pleural effusion, mild TR, PR. • Cranial CT Scan • Normal findings

  25. Working Impression Systemic lupus erythematosus in activity t/c SLE cerebritis, myocarditis t/c sec APAS Community Acquired Pneumonia r/o SOL vs electrolyte imbalance vs CNS infection as cause of seizure Anemia of chronic disease Complicated UTI

  26. Title content

  27. Jonsen’s Method

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