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Systemic Lupus Erythematosus

Physical Exam

Height: 64"
Weight: 108 lbs
Temperature: 99.6°F
HR: 82 bpm
Resp: 20/min.
BP: 112/70

Mrs. Evan exhibits the following signs: joint stiffness and swelling especially noted in her hands and wrists bilaterally. Her right knee is also noted to have some swelling along with decreased range of motion (ROM). It is also noted that her weight had decreased by 10 pounds since her miscarriage.

On exam, Dr. Smith did not find an abdominal mass and there was no tenderness on palpation of the abdomen. No heart murmur or irregularity is noted in Mrs. Evan's heart rate on auscultation. Dr. Smith orders lab tests including complete blood count (CBC), chemistry profile, thyroid panel, erythrocyte sedimentation rate (ESR), and a urinalysis. X-rays of Mrs. Evan's hands and knees bilaterally and an abdominal ultrasound are ordered.

Dr. Smith explains to Mrs. Evan that she suspects a rheumatic condition, but must also rule out the possibility of a more acute problem such as an infection or thyroid disorder. Dr. Smith explains that joint stiffness and swelling along with the decreased ROM, the fatigue, and low-grade fever suggest the presence of a rheumatic condition.

In addition to the physical exam and diagnostic tests, Dr. Smith takes a detailed history and requests that Mrs. Evan keep a daily log of her temperature. At the conclusion of her visit, Mrs. Evan is given the schedule for her tests and is told she can expect a phone call with the results in approximately 48 hours.