Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with acute onset of dyspnea, non-productive cough, and pleuritic chest pain. Known history of SLE. Symptoms rapidly progressive over [Number] days. Denies fever, chills, or purulent sputum. No recent travel or sick contacts. Current SLE medications: [Medication list].
Clinical Examination Findings
Vitals: Tachypneic (RR: [Number]), O2 saturation [Number]% on room air. Pulmonary: Bilateral basal crackles, decreased breath sounds at lung bases. Cardiac: Tachycardia, regular rhythm, no murmurs. Skin: Malar rash present/absent, no digital vasculitis. Extremities: No peripheral edema.
Treatment Protocol
Initiate high-dose systemic corticosteroids (e.g., IV Methylprednisolone). Consider escalation to immunosuppressive therapy (e.g., Cyclophosphamide or Mycophenolate Mofetil) if refractory. Supplemental oxygen to maintain SpO2 >92%. Monitor ABG and serial chest imaging. Prophylaxis for PJP if on high-dose steroids.