Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with chronic sicca symptoms, including persistent xerophthalmia (gritty sensation, photophobia) and xerostomia (difficulty swallowing dry foods, need for liquids). Reports associated fatigue, arthralgia, and occasional parotid gland swelling. Denies current ocular infection or dental abscess.
Clinical Examination Findings
HEENT: Significant xerostomia noted with dry, erythematous oral mucosa and fissured tongue. Parotid glands are mildly enlarged and non-tender. Ocular exam reveals decreased tear film meniscus and conjunctival injection. Lymphadenopathy: None palpable. Musculoskeletal: No active synovitis or joint deformities.
Treatment Protocol
Initiate symptomatic management: Preservative-free artificial tears (QID/PRN) and oral lubricants. Consider secretagogues (e.g., Pilocarpine or Cevimeline) if refractory. Emphasize rigorous dental hygiene to prevent caries. Monitor for systemic involvement (e.g., vasculitis, pulmonary, or renal).