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D.W. is a 29-year-old married woman with three children under 5 years of age. She saw her provider 7 months ago with intermittent fatigue, joint pain, low-grade fever, and unintentional weight loss. Her provider noted small, patchy areas of vitiligo and a scaly rash across her nose, cheeks, back, and chest at that time. Lab studies showed D.W. had a positive antinuclear antibody (ANA) titer, positive anti-dsDNA test, positive anti-Sm test, elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and decreased C3 and C4 serum complement. Joint -ray films showed joint swelling without joint erosion. D.W. was diagnosed with systemic lupus erythematosus (SLE). Initial treatment consisted of hydroxychloroquine (Plaquenil), prednisone, and naproxen sodium, and ice packs. D.W. responded well and the steroid was tapered and stopped. She was told she could follow up every 6 months unless her symptoms became acute. D.W. resumed her job in medical billing at a large geriatric facility.
Twenty-eight months after diagnosis, D.W. seeks out her provider, saying that she has increased fatigue and puffy hands and feet. D.W. reports that she has been working long hours because of the absence of two co-workers who are on maternity leave.
Laboratory Test Results:
D.W. is seen in the immunology clinic twice monthly during the next 3 months. Although her condition does not worsen, her BUN and creatinine remain elevated. While at work one afternoon, D.W. begins to feel dizzy and develops a severe headache. She reports to her supervisor, who has her lie down. When D.W. starts to become disoriented, her supervisor calls 911, and D.W. is taken to the hospital. D.W. is admitted for probable lupus cerebritis related to acute exacerbation of her disease.
The provider orders pulse therapy with methylprednisolone IV every 6 hours and plasmapheresis once daily.
You go to assess D.W. What do you need to include in your assessment?