Session 4 - Group Work Flashcards
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
a) What are your differential diagnoses for her current Emergency Department presentation?
In thinking about the possible diagnoses you need to appreciate that Rheumatoid arthritis can affect many systems of the body. There is a diagram at the end of this case study (and in Kumar and Clark) of the non-articular manifestations of rheumatoid arthritis. In addition, the inflammatory and immune process triggered by rheumatoid arthritis can negatively impact on a range of pre-existing disorders - see further diagram taken from a NEJM article.
And you must always be aware that a patient with one condition may well have other medical problems that have their own complications. You studied chronic obstructive pulmonary disease (COPD) in the Respiratory Unit. You may want to look up some basic information on COPD. See if you can come up with 3 or 4 possible diagnoses.
- pneumonia
- LRTI
- infective acute exacerbation of COPD
- heart failure (HF)
- TB
- SLE
- pulmonary embolism (PE)
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
b) You request a chest x-ray to evaluate her cough and shortness of breath. See image below.
i) What are the differentials for the chest imaging in this patient?
In thinking about the chest X-ray, think broadly as to what might cause the abnormal shadows.
Patients with rheumatoid arthritis have an immune system that is activated (but in some areas is dysfunctional) and the treatment for rheumatoid arthritis is designed to reduce the immune response. It is possible that these patients are ‘immunocompromised’. You covered the immunocompromised patient in the Infection Unit and you may recall some of the infections that occurred and a chest X-ray you looked at that was similar to this one.
You can also look at some of the systemic features of rheumatoid arthritis
- lymphoma
- cancer from another primary site that has metastasised to the lung
- Caplan’s syndrome
- Rheumatoid nodules
Methotrexate - key side effect, can cause lung fibrosis
Also she is at risk of getting atypical pneumonia
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
b) You request a chest x-ray to evaluate her cough and shortness of breath. See image below.
ii) What do you do next?
The Tutors will tell you what this showed.
- A CT scan
- sputum sample
- look at previous imaging of her x-rays.
Previous imaging showed the nodules were there 2 years ago in her previous chest x-ray, so she’s fine, this is just an exacerbation of the RA.
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
c) Her blood tests done on arrival to the ED are now available for review.
See figure below.
i) What is the likely diagnosis based on these results?
Acute infective process
The WBC count might be reduced anyway bc of the methotrexate (immunosuppressed) so then it is raised but shows as within normal range
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
c) Her blood tests done on arrival to the ED are now available for review.
See figure below.
ii) What is the D-dimer test?
D-Dimer is a test for fragments of blood clotting
Most doctors agree that a negative D-dimer is most valid and useful when the test is done on patients that are considered to be low-risk (e.g. has PE then unlikely to do D-Dimer)
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
c) Her blood tests done on arrival to the ED are now available for review.
See figure below.
iii) What does the D-dimer test result suggest?
A normal D-dimer test means that it is most unlikely you have an acute blood clot or disease causing abnormal clot formation and breakdown. Most doctors agree that a negative D-dimer is most valid and useful when the test is done on patients that are considered to be low-risk.
1) A 69yr old lady with a 15-year history of poorly controlled rheumatoid arthritis presents to the emergency department. She has had a 3-day history of cough productive of greenish yellow sputum. She has had a day’s history of worsening shortness of breath, which prompted her visit to the ED.
Apart from RA, her past medical history includes hypertension, COPD and gastroesophageal reflux disease.
She is on Ramipril, lansoprazole and takes methotrexate for her rheumatoid arthritis.
She has a 20-pack year smoking history.
Her shortness of breath is not present at rest. You have been told to assess her.
c) Her blood tests done on arrival to the ED are now available for review.
See figure below.
iv) What steps do you take next?
If you consider that a chest infection is a possibility, you will recall from the Infection Unit that we referred you to the UHL Antimicrobial website. You can access this via the Infection Unit on BlackBoard or the RxGuidline App. It has guidance on the assessment of pneumonia; which you covered in the Respiratory Unit.
UHL Guidelines:
Respiratory –> Community-acquired pneumonia –> CURB-65
Amoxicillin
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
a) What are the differential diagnoses you consider for this current presentation?
- poorly controlled SLE
- nephritis (at risk due to ibuprofen)
- leukaemia
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
b) She had blood tests and a urine dipstick done. The blood tests are still awaited but the urine dipstick is available. See image below.
In the Urinary Unit, you learnt that the finding of blood and/or protein in the urine is almost always abnormal. Blood can come from anywhere in the urinary tract. The combination of blood and protein in the urine usually implies an abnormality of the glomerulus.
i) What abnormalities are indicated in the urine dipstick?
Blood Slightly more acidic pH WBCs Protein Nitrites
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
b) She had blood tests and a urine dipstick done. The blood tests are still awaited but the urine dipstick is available. See image below.
In the Urinary Unit, you learnt that the finding of blood and/or protein in the urine is almost always abnormal. Blood can come from anywhere in the urinary tract. The combination of blood and protein in the urine usually implies an abnormality of the glomerulus.
ii) What possible causes do you consider?
- Lupus nephritis
- Glomerular nephritis
- Renal calculi
- Pyelonephritis
- AKI
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
b) She had blood tests and a urine dipstick done. The blood tests are still awaited but the urine dipstick is available. See image below.
In the Urinary Unit, you learnt that the finding of blood and/or protein in the urine is almost always abnormal. Blood can come from anywhere in the urinary tract. The combination of blood and protein in the urine usually implies an abnormality of the glomerulus.
iii) What investigations would you do based on this result?
- Kidney ultrasound
- Biopsy
- Bloods
- Immunofluorescence assay
- Urine culture
- Protein:creatinine ratio (assess the protein levels in urine)
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
b) She had blood tests and a urine dipstick done. The blood tests are still awaited but the urine dipstick is available. See image below.
In the Urinary Unit, you learnt that the finding of blood and/or protein in the urine is almost always abnormal. Blood can come from anywhere in the urinary tract. The combination of blood and protein in the urine usually implies an abnormality of the glomerulus.
iv) What do you do next?
- Tell the patient, nephrologist and rheumatologist
- Restart the lupus medication/ask her why she’s not taking it
- Stop the NSAIDs
- Put her on diuretics
2) A 22yr old Caucasian lady with SLE diagnosed 3 months ago presents to her GP with complaints of generalized body pains of 7 days. She also gives a history of bilateral feet swelling for the last 2 weeks.
She smoke 10 cigarettes per day and drinks only on social occasions.
She cannot remember the name of her medication for lupus as she admits to infrequent use. She has however taken ibuprofen consistently for the last 1 week.
Apart from irritable bowel syndrome, she has no other past medical history of note.
She is concerned about her recent symptoms and seeks to know what is happening, as she is unable to continue with her studies at university.
c) Her bloods are now available. You are asked to review are autoimmune panel. See image below
Additional blood tests show:
Her CRP is elevated at 50 (normal <5),
Her creatinine is elevated
She has an eGFR of 50 (normal >90).
NOTES
Serum creatinine is an important indicator of renal health because it is an easily measured byproduct of muscle metabolism that is excreted unchanged by the kidneys. If the filtration in the kidney is deficient, creatinine blood levels rise. A rise in blood creatinine level is a late marker, observed only with marked damage to functioning nephrons.
Glomerular filtration rate (GFR) describes the flow rate of filtered fluid through the kidney
The eGFR is the estimated glomerular filtration rate and is calculated from a blood test.
If the GFR falls and is below normal it implies the kidney and glomerulus is not working properly
i) What is the likely diagnosis (or diagnoses) and ii) why is the CRP elevated?
i) Likely diagnosis: SLE with a urinary tract infection
ii) Presence of antibodies led to complement activation - this is an acute exacerbation so the CRP has gone up, but normally it’s controlled bc she should be taking her medication.
However, it is likely she concurrently has a UTI, so the CRP is due to the UTI (which is indicated in the raised nitrites).
