1. Case Presentation Linda White, PA-S

2. Chief Complaint n “ I am short winded and tired. Also when I eat it feels like the food sits in my chest.”

3. History of Present Illness n 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.

4. Past Medical History n Currently being followed by SLE clinic for presumptive Dx of SLE (Connective Tissue Disorder Workup) n Pericardial Effusion - 9/13/00. Treated by pericardial window. n Hysterectomy 1988 - Dysfunctional Uterine Bleeding n Right Breast Lumpectomy 1987 - benign n Blood Transfusion - 1987 n Chronic Anemia - Diagnosed 1987 n History of Hypertension - Treated with Lasix 40mg/day/P.O.

5. Past Medical History Continued n Allergies - PCN n Meds - Lasix 40 mg P.O. q day, Naproxen 250mg P.O. BID n Social Hx - Noncontributory n Fam Hx - Brother with MI, HTN; daughter RA since age 2

6. ROS n General - easy fatigability n Hematopoetic - chronic anemia, Hx of transfusions, Denies bleeding per rectum n Other ROS noncontributory

7. Physical Examination n General - 60 yo African American female who looks older than stated age. Cachectic appearance, lethargic though in no apparent distress. AO x 3 n Vitals - P: 72/min, T: 97.1, RR: 18/min, BP 120/70 supine and 115/65 sitting. n HEENT - Inc. JVD, no lymph nodes

8. Physical Examination Con’t n Chest - No wheezes or rales, decreased breath sounds L base n Cardiac - s1, s2 normal; no audible murmur n Abdomen - LLQ tenderness, no palpable masses n Rectal - negative guaiac n Ext - no edema

9. Labs (Abnormals) n K - 7.4(hemolyzed), BUN - 45, Creat - 1.7 n Hgb - 7.5, Hct - 24.1, MCV 89, ESR - 120 n FANA +, ANA 640 n CXR - borderline cardiomegaly with left pleural effusion n EKG - sinus bradycrdia 52/min

10. Impressions n Anemia (chronic) - rule out iron deficiency anemia due to blood loss, connective tissue chronic disease anemia, hemolysis n Pericardial Effusion by Hx - rule out malignancy, pericarditis, uremia n Prerenal Azotemia - volume depletion, cardiac insufficiency, liver disease n Dysphagia - rule out esophageal malignancy, achalasia, nutcracker esophagus n Connective Tissue Disorder - SLE

11. SLE n Chose to speak about SLE as it can cause many of the symptoms this patient is experiencing n Occurs at any age and ranges from mild dermatologic and joint symptoms to organ failure n More common in women and most severe in blacks and hispanics

12. Etiololgy n Unknown but immune complex formation support an immunologic origin

13. Clinical Manifestations n Any organ system n Systemic - malaise/fatigue n Vascular - Raynaud’s phenomenon n Renal - proteinuria, lupus nephritis, glomerular destruction n Pulmonary - pulmonary hemorrhage n Cardiac - pericarditis n Hematologic - anemia both hemolytic and non-hemolytic

14. Diagnosis n Clinical as no one test or feature is fully diagnostic n Antinuclear antibodies

15. Treatment n No cure has been found n Immunosuppresive agents n NSAIDs n Corticosteroids