The History of Present Illness

Chief Complaint: The patient is a 35-year-old woman who expresses concern about a rash on her face.

History of Present Illness: The patient has had a rash across the face and the bridge of the nose for a week. It first appeared after the patient spent the holidays hiking in the Appalachian Mountains. She has never had such lesions before. They cause itching and pain and get worse after the patient goes outdoors. She has also noticed having a fever, getting tired more, and losing weight. The patient states that she doesn’t suffer from headache, sore throat, ear pain, nasal or sinus congestion, chest pain, shortness of breath, cough, abdominal pain, and pain with urination, constipation, or diarrhea. The patient has mouth soreness, muscle aches and pains, especially in her hand and wrist. She doesn’t experience early morning joint stiffness and is able to move in the morning without difficulty. The patient is not heating intolerant and does not have polyuria, polydipsia, or polyphagia.

Past Medical History: The patient had a tonsillectomy performed on her when she was 9 because she was diagnosed with chronic strep throat infections. Her general health as an adult has been good.

Family History: The patient has a mother, who suffers from rheumatoid arthritis, and a healthy father.

Personal History: The patient has a steady boyfriend, with whom she has been living for the past 5 years. She has no children. There is no history of smoking, alcohol or substance abuse.

Social History: The patient has a master’s degree in engineering and works as an electrical engineer.

Vital Signs: Temperature: 100.3°F. Blood pressure: 112/66 mm Hg. Pulse is regular, 62 beats per minute. Respiratory rate: 12 breaths per minute.

General State: The patient is a 35-year-old woman with no signs of extreme pain or discomfort.

Mental Status: No signs of mental disorders were detected.

Skin: The patient has a malar (butterfly) rash – erythematous plaques on her cheeks and the bridge of her nose, but not on the nasolabial folds.

Head: NC/AT.

Eyes: The color of the sclera is white, conjunctivae are clear, pupillary constriction from 4 mm to 2 mm is observed, pupils are equal and round, they react to light and accommodation.

Ears: Hearing is not tested, the patient expressed no complaints.

Nose: No discharge, no obstruction.

Throat and Mouth: There is erythema without exudates in the posterior pharyngeal wall. Several shallow ulcers are found on both sides of the oral mucosa.

Neck: Neck is supple. No signs of cervical lymphadenopathy or thyromegaly were found.

Chest and Lungs: Respiratory rate is normal, diaphragm movement is normal.

Breast: Not tested.

Heart: Heart rate is regular, patient denies having pains.

Abdomen: Not tested. No abdominal pain is observed.

Endocrine and Genitourinary: Not tested. The patient denies pain with urination, constipation, or diarrhea.

Musculoskeletal System: Patient complaints of muscle ache and pains, especially in the hand and wrist.

Neurologic System: Awake, alert and fully oriented. Motor: Strength not tested, moves all extremities.

Presumptive nursing diagnosis for a patient with the above-listed complaints and physical examination results in mild systemic lupus erythematosus in the early stage of development. The patient has enough symptoms of the disease to justify the diagnosis, e. g. the malar rash, which gets worse in the sun, the feeling of fatigue, low-grade fever, and pain in the hand and wrist, the smaller joints of which are usually affected first (Rhines, 2012), in addition to having a close relative with a history of rheumatoid arthritis and having recently spent some time under the sun (namely, hiking in the mountains), which can spark lupus. According to Rhines (2012), “In mild and moderate lupus, symptoms are mostly confined to the skin and the joints” (p. 37) and the illness does not affect internal organs. However, “It is not unusual for new symptoms to appear over time and for symptoms to become worse” (Rhines, 2012, p. 37). Therefore it is extremely important to diagnose the disease as soon as possible and to control its progress. Since this is a chronic disease, the goal is to mitigate its symptoms, slow down its development and prolong the periods of remission. Although some patients can “go into remission without medication” (Rhines, 2012, p. 37), it is essential to monitor their state and to keep them informed about how they can better their condition.

Teaching patients about their illness goes far beyond telling them what medicine to take. According to Rhines (2012), “Being well-informed makes a person with lupus a better partner in the treatment” (p. 37). This is vital, because in the case of lupus, “Symptoms vary from person to person” (Carpenito, 2014, p. 599). Teaching patients what to expect and what symptoms to look for would raise their self-awareness and help them determine how the illness affects them, personally, to notice some patterns in the “relapsing and remitting course” (Carpenito, 2014, p. 599) that they might otherwise overlook, especially if the symptoms are mild. Therefore, introducing some basic information would be the first intervention in the nursing care plan.

Lupus shares many of its symptoms with other illnesses, so before making a definite diagnosis and starting treatment for it, some tests should be run. According to Gulanick and Myers (2011), “A variety of immunologically based tests may be performed (e.g., antinuclear antibody [ANA], erythrocyte sedimentation rate [ESR], serum protein electrophoresis, rheumatoid factor, serum complement)” (p. 783). Thus, the second intervention would be to inform the patients about the tests and their role in the diagnosis.

The third step would be to describe the effects of the prescribed medication, to make sure that the patient understands when and how much of it to take. It’s useful to reiterate the importance of taking the medicine according to prescribed doses and times. Since the drugs for Lupus (e.g. corticosteroids) are mostly aimed at suppressing the “malfunctioning” immune system, patients should be notified about the possible side effects as well.

According to Gulanick and Myers (2011), “New therapies for lupus are being researched all the time” (p. 784). That is why a nurse should always keep up with the latest developments and be able to recommend some of them to the patients. They would benefit not only from the therapy itself but also from the very knowledge that their disease is being researched and there are new ways to help them deal with it.

Patients should also be instructed to look out for signs of lupus progressing to the internal organs, monitor their temperature, try to avoid spending a lot of time in the sun, and relax more (Gulanick and Myers, 2011, pp. 784-789).

Although it may seem simple, patient teaching is much more than memorizing and regurgitating a to-do list. According to Allbee et al. (2012), it includes “assessment for readiness to learn, preferred methods of learning, understanding of what is taught, and the repetition of teaching to reinforce the desired outcome” (p. 218). Besides, as is common with chronic diseases, a patient with lupus must realize that it can be controlled and treated and that people can enjoy their lives even with this diagnosis. An understanding and sensitive nurse can help people keep a positive outlook and fight for their well-being.


Allbee, B. H., Marcucci, L., Garber, J. S., Gross, M., Lambert, S., McCraw, R. Jr., … Slonim, T. A. (2012). Avoiding Common Nursing Errors. Beijing: Lippincott Williams & Wilkins.

Carpenito, L. J. (2014). Nursing Care Plans: Transitional Patient & Family-Centered Care. Beijing: Lippincott Williams & Wilkins.

Gulanick, M. & Myers, Judith L. (2011). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. St. Louis: Elsevier Health Sciences.

Rhines, K. (2012). Lupus. Minneapolis: Twenty-first Century Books.

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