Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a known history of SLE, reporting a flare of polyarthropathy characterized by symmetrical joint pain, morning stiffness lasting >60 minutes, and localized swelling. Symptoms involve [specify joints, e.g., PIP, MCP, wrists], exacerbated by activity and improved with rest. Denies current fever, malar rash, or pleuritic chest pain.
Clinical Examination Findings
General: Patient is alert and oriented, in no acute distress. Musculoskeletal: Symmetrical synovitis noted in [specify joints]. Tenderness to palpation present over [specify joints] with limited range of motion due to pain. No evidence of joint deformity or erosive changes. Skin: No active malar rash, discoid lesions, or photosensitivity noted at this time.
Treatment Protocol
Initiate/Adjust therapy with [Hydroxychloroquine 200-400mg daily / NSAIDs for symptom control / Prednisone taper]. Monitor for potential side effects. Advise strict adherence to medication regimen. Follow up in [timeframe] for repeat labs including CBC, ESR, CRP, and renal function.