Systemic Lupus Erythematosus Case Study: Difference between revisions

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== Outcomes  ==
== Outcomes  ==


With physical therapy intervention, the patient was able to reach her goals. She has returned to work and is able to perform household duties in the absence of pain and with minimal fatigue. By discharge, the patient was in a remissive state with complete absence of pain in bilateral knees and elbows<ref name="1" />.<br> <br>Self Report Outcome Measure:<br>• Systemic Lupus Activity Measure-Revised (SLAM-R): 50/81<br>Physical Performance Measures:<br>• 5 sit to stands in 13 seconds<br> <br>The patient’s improvement on the SLAM-R indicates decreased disease activity and disease severity<ref name="8" />.<br>The patient’s improvement on the Five Times Sit to Stand Test indicates increased functional lower limb muscle strength. <br>
With physical therapy intervention, the patient was able to reach her goals. She has returned to work and is able to perform household duties in the absence of pain and with minimal fatigue. By discharge, the patient was in a remissive state with complete absence of pain in bilateral knees and elbows<ref name="1" />.<br> <br>Self Report Outcome Measure:<br>• Systemic Lupus Activity Measure-Revised (SLAM-R): 50/81<br>Physical Performance Measures:<br>• 5 sit to stands in 13 seconds<br> <br>The patient’s improvement on the SLAM-R indicates decreased disease activity and disease severity<ref name="8" />.<br>The patient’s improvement on the Five Times Sit to Stand Test indicates increased functional lower limb muscle strength<ref name="10">Jason Raad. Five Times Sit to Stand Test. http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=1015 (assessed 24 March 2015)</ref>. <br>


== Discussion  ==
== Discussion  ==

Revision as of 22:53, 29 March 2015


Author/s[edit | edit source]

Sara Gress, Kelly Mudlo, Micheal Rangel, and Shelby Wagoner from the Bellarmine University Physical Therapy Program's Pathophysiology of Complex Patient Problems Project.

Definition/Description[edit | edit source]

Lupus erythematosus, sometimes referred to as lupus, is a chronic inflammatory autoimmune disorder that appears in several forms; discoid lupus erythematosus (DLE), which affects only the skin, and systemic lupus erythematosus (SLE), which can affect any organ or system of the body. Other forms include drug-induced lupus, antiphospholipid antibody syndrome, and late-stage lupus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Systemic lupus erythematosus belongs to the family of autoimmune rheumatic disorders that can be characterized by injury to skin, joints, kidneys, heart and blood-forming organs, nervous system, and mucous membranes. Discoid lupus is a limited-form of the disease confined to the skin presenting as coin-shaped lesions, which are raised and scaly. Discoid lupus rarely develops into systemic lupus. Systemic lupus is usually more severe than discoid lupus and can affect almost any organ or system of the body. For some people, only the skin and joints will be involved. In others, the joints, lungs, kidneys, blood, or other organs or tissues may be affected.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


Background/Prevalence[edit | edit source]

The exact cause of SLE is unknown, although it appears to result from an immunoregulatory disturbance brought about by combination of genetic, hormonal, chemical, and environment factors. Some of the enviormental factors that may trigger the disease are infections (e.g., Epstein-Barr virus), antibiotics, and other medications, exposure to ultraviolet light, extreme physical and emotional stress, including pregnancy. Although there is a known genetic predisposition, no known gene is associated with SLE.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


  • Relatively rare disease which occurs in 15-124/100,000 of the population worldwide.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Most common in persons between the ages of 15-40 years.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Rarely occurs in the elderly population. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Women are affected 10-15x more often than men. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • About 6-19% of lupus patients, the diagnosis was made after the fifth and sixth decades of the patients life.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • During the disease course, discoid rash lesion is significantly more common in men compared to females.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • The disease is 2-4x more frequent and severe in among nonwhite populations around the world and tends to be more severe in men, pediatric, and late-onset lupus.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • More prevalent in first-generation family history more often when compared to the general population.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Patient Characteristics[edit | edit source]

Patient demographics

  • Patient is a 46 year old caucasian female who works full time as a secretary. She presented to the hospital with a six-month history of generalized weakness and significant weight loss of 40 lbs.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Current diagnosis

  • Systemic Lupus Erythematosus, acute inflammatory arthritis of elbows and knees.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Co-morbidities

  • Hypertension: unmanaged by medications due to financial constraintsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Obesity: BMI 28

Previous care or treatment

  • This patient has been treated for past episodes of leukopenia on more than two occasions.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Examination[edit | edit source]

Subjective:

  • Patient presented to the hospital with a six-month history of generalized weakness and significant weight loss of 40 lbs over the past 4 months. Over the past two weeks, she has been having progressing symptoms of worsening dyspnea.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title She has been unable to do yard work due to her fatigue and pain in her elbows and knees. She has had to take leave from work for several weeks due to her inability to type and sit for long periods of time.

Patient History and Systems Review:

  • Patient has no history of smoking, drug, or alcohol use. She has had a history of leukopenia on several occasions, but this episode of symptoms seems to be the most exaggerated.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title She has not hospitalized for any other relevant conditions. Her goals are to return to work and to be able to perform household duties with less pain and fatigue.

Self Report Outcome Measure:

  • Systemic Lupus Activity Measure-Revised (SLAM-R): 20/81Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive titleCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical Performance Measures: 

  • 5 sit to stands in 30 seconds 

Objective :

  • Blood pressure: 102/66 mm/HgCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Heart Rate: 88 bpmCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Temperature: Normal
  • Respiratory Rate: 24 breaths/minCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Oxygen saturation: 92%Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Lab results revealed anemia, leukopenia, elevated blood urea nitrogen, and elevated creatinine. Urinalysis showed trace proteinuria.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Serological work-up: high anti-nuclear antibody, anti-double stranded DNA antibody, and anti-Smith antibody titersCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Physical Examination

  • Integumentary observation: Patient presented with mucosal pallor, showed no signs of cyanosis, digital clubbing, pitting edema, skin rash, or joint deformities.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Palpation/percussion: Examination and palpation of patient’s distended abdomen was non-tender to palpation. Palpation of lymph nodes revealed rubbery axillary and inguinal lymphadenopathy.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Respiratory system: Decreased breath sounds and dullness to percussion were noted on the left base.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • Cardiovascular and Neurological: UnremarkableCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title
  • ROM: Painful ROM in bilateral elbows and knees. All other joints WNL
  • MMT: Generalized weakness
  • Picture of patient malar rash presentation 
    SLE rash.jpgCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Clinical Impression[edit | edit source]

According to the signs and symptoms this patient is presenting with, it was evident to her physician and other health care providers that she was experiencing progressing symtoms of systemic lupus erythematosus. It was recommended that she start the appropriate treatment which included physical therapy intervention. This patient was diagnosed early enough that the appropriate treatment could result in the desired positive outcome.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

 

Intervention[edit | edit source]

  • Phases of Interventions (e.g. protective phase, mobility phase, etc.)
  • Dosage and Parameters
  • Rationale for Progression
  • Co-interventions if applicable (e.g. injection therapy, medications)

Outcomes[edit | edit source]

With physical therapy intervention, the patient was able to reach her goals. She has returned to work and is able to perform household duties in the absence of pain and with minimal fatigue. By discharge, the patient was in a remissive state with complete absence of pain in bilateral knees and elbowsCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Self Report Outcome Measure:
• Systemic Lupus Activity Measure-Revised (SLAM-R): 50/81
Physical Performance Measures:
• 5 sit to stands in 13 seconds

The patient’s improvement on the SLAM-R indicates decreased disease activity and disease severityCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.
The patient’s improvement on the Five Times Sit to Stand Test indicates increased functional lower limb muscle strengthCite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title.

Discussion[edit | edit source]

      When treating a patient with Systemic Lupus Erythematosus, patient education is key. It is important to inform them that refraining from smoking and protecting their skin from the sun can drastically improve their disease severity. Photosensitivity occurs in 75% of individuals with SLE. Smoking drives hypertension common in SLE and interferes with the benefit of hydroxychloroquine (Plaquenil), an anti-malarial drug used to treat SLE. Educating the patient about continuing their exercise regimen after they are discharged from physical therapy treatment is beneficial. Regular exercise helps prevent fatigue and joint stiffness. Furthermore, regular, moderate physical activity can prevent the neuroendocrine and detrimental immunological effects of stress. This is particularly important for an individual with an autoimmune disorder.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


  During a stent of treatment, since the physical therapist will see the individual with SLE frequently, it is important to be a “physician extender” of sorts. Due to training in differential diagnosis, physical therapists are equipped with the knowledge to determine when a patient needs to be referred back to their primary care provider. Physical therapists should monitor any patient on corticosteroids or immunosuppressants for signs of infection. Avascular necrosis is a possibility in those on corticosteroids, most commonly in the femoral head. Another less probable site is the femoral condyle of the knee. If the patient exhibits insidious onset of unilateral hip or knee pain that is worse with ambulation but often present at rest with symptoms present over weeks to months, refer to primary care provider.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title


   Be aware of any changes in bone density and screen for the presence of developing osteoporosis before including any resistive exercise, muscle-energy techniques or self-mobilization techniques. This may be a side effect of years of steroidal anti-inflammatory medications. Long term steroid therapy has been linked to diabetes mellitus, hyperlipidemia, and obesity. Observe for any renal involvement. Signs may include weight gain, edema, or hypertension. If there are signs of cognitive decline, this is a reason for referral. Raynaud’s phenomenon may become present. If so, inform the patient of the importance of warming and protecting the hands and feet. Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

In conclusion, it is important to know the comorbidities of SLE in order to know when a referral is appropriate.Cite error: Invalid <ref> tag; name cannot be a simple integer. Use a descriptive title

Related Pages[edit | edit source]

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References[edit | edit source]



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