SGD CASE WEEK 23

INSTRUCTIONS:

1. Read the case presented below. It is constructed in a way to help us correlate clinically the topics
in the basic sciences.
2. Concept guides will be provided to assist you in which topics to study.
3. Please refer to the booklet on “Scored Group Discussion” by Richard Lander at the end of this
handbook. We will be using most of the elements discussed unless otherwise specified.
4. Length of Time: 3 hours per meeting.
5. Time for Preparation: 1 week prior to schedule of meeting.
6. Rotating roles of group members: Leader, secretary, moderator
a. Leader: secures copy of case, assigns roles, initiates case discussion
b. Secretary: checks attendance, lists ideas, writes down concept map for discussion
c. Moderator: keeps flow of discussion on track and mediates arguments
7. Speak English during the discussion.
8. Present a concept map at the end of the SGD. Please use link for reference in concept map
construction. https://www.youtube.com/watch?v=FSrlIP3yVjs

LEARNING OBJECTIVES:

1. To present a case of a 26 years old female who presented with bilateral leg swelling.
2. Appreciate important symptoms in the history to arrive at a diagnosis.
3. Correlate physical examination findings with disease pathogenesis.
4. Understand the different risk factors and pathogenesis of rheumatologic diseases.
5. Interpret laboratory findings with disease pathogenesis.
6. Present a concept map of the understanding of the case.

CASE:

GENERAL DATA

Mary Joy is a 26-years-old, female, Filipino, single, Roman Catholic, from Urgello, Cebu, admitted for the
first time in SWU – MC.

CHIEF COMPLAINT: bilateral leg swelling

PAST MEDICAL HISTORY

She is non hypertensive, non-diabetic, non-asthmatic. No previous hospitalizations nor surgeries.

PERSONAL / SOCIAL HISTORY

Mary Joy is a non-smoker, non-alcoholic beverage drinker, denies history of illicit drug use.

She works as a cashier in a department store within the city. She has no formal diet nor exercise regimen.

FAMILY HISTORY

Her father is hypertensive with good compliance to maintenance medications. No other known heredo-
familial diseases were noted.
HISTORY OF PRESENT ILLNESS

Two months prior to admission, Mary Joy noted intermittent episodes of joint pains specifically both knees
and upper digits. The pain was sharp in character, with decrease in movement of affected joints, and was
associated with undocumented fever. She took paracetamol 500mg/tab with relief of symptoms. No
consultation was done, condition was tolerated.

One month prior to admission, she noted persistence of joint pains. She noted that her hair was easily
falling out and that she has a foamy urine. She consulted with her private doctor and was treated as a
case of urinary tract infection and given cefuroxime 500mg/tab, 2 times a day for 7 days with good
compliance. No diagnostic work-up done.

Two weeks prior to admission, she noted to have the same symptoms and was now associated with body
malaise and easy fatiguability. She self-medicated with multivitamins and iron supplements. No
consultation was done, condition was tolerated.

One day prior to admission, she still has the same symptoms but was now associated with bilateral leg
swelling prompting her to seek consultation at SWU – OPD and was later advised admission.

PHYSICAL EXAMINATION

General: examined conscious, coherent, cooperative, not in respiratory distress, with the following vital
signs

BP: 120/80 mmHg HR: 89 BPM RR: 19 CPM T: 37 C

Skin: warm and dry, slightly raised erythema over the cheeks and nose, noted palmar pallor

HEENT: anicteric sclerae, pale palpebral conjunctivae, no tonsillar exudates, neck is supple

C/L: no retractions nor deformities, equal chest expansion, clear breath sounds

CVS: distinct heart sounds, normal rate, regular rhythm, no murmurs

Abd: flat, normoactive bowel sounds, soft, non-tender all quadrants, no organomegaly

Ext: swelling 2nd to 5th digits both upper extremities and both knees, non-tender, strong peripheral pulses,
capillary refill time less than 2 seconds, bilateral grade 2 pitting edema, lower extremities.

Neuro: within normal limits.

PERTINENT DIAGNOSTIC FINDINGS

Examination Results
Anti-nuclear antibodies 1:240
C3 8 mg/dl
Anti-DsDNA 200 IU/ml
Coombs test (direct) positive
CONCEPT GUIDE

General pathology: Disorders of the immune system

Clinical pathology: Clinical and laboratory evaluation of systemic rheumatic diseases

Pharmacology: Immunopharmacology

RECOMMENDED RESOURCES:

• Bates’ Guide to Physical Examination and History Taking 12th edition

• Robbins and Cotran Pathologic Basis of Disease 9th edition
• Henry’s Clinical Diagnosis and Management by Laboratory Methods 23rd edition
• Katzung Basic and Clinical Pharmacology 14th edition