Follow up DFASM3 2 – Shortness of Breath

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Shortness of Breath

 

Where?

Emergency Medicine Department at Mayo Clinic Hospital

Doctor’s name and Position

Jeremy Daven - Attending physician
Emily Eastwich - Second year resident

Patient’s name:

Edna Zlock

Age:

43

Marital status:

Married

Presenting complaint:

-    5-day history of increasing shortness of breath → limiting daily activities
-    Mild, non-productive cough
-    No fever, chills, chest pain, or palpitations

Past medical history:

-    Shortness of breath for 1 year, gradually progressive
-    No sick contacts
-    No recent travel
-    Asthma
-    Hypertension
-    Several episodes of presumed bronchitis or pneumonia in the past year → ATB by primary care provider
-    Heavy menstrual periods
-    OCPs
-    Family history: DM + ischemic heart disease
-    Non-adherent ACE inhibitor, inhaled corticosteroid, beta-2 agonist
-    Quit smoking 10 years before (20-pack-year history)
-    No alcohol or illicit drug use
-    No known allergies

O/E:

-    No acute distress
-    Morbidly obese
-    BMI of 45
-    BP 170/95
-    HR 106
-    Respiratory rate18
-    Temperature 98.6°F
-    O2 sats 97% while breathing ambient air
-    Chest examination: fine crackles at the lung bases + decreased vocal fremitus
-    Normal first and second heart sounds
-    No jugular venous distention, murmurs, rubs, or gallops
-    Several enlarged, non-tender cervical and axillary lymph nodes bilaterally
-    No rashes
-    Non-focal neurologic examination
-    Palpable peripheral pulses
-    Mild bilateral pitting pedal edema

Further investigations:

-    Electrocardiogram
-    Blood tests
-    X-ray and CT-scan of the chest
-    Biopsy of the kidney

Results:

-    EKG: sinus tachycardia
-    Creatinine of 1.6
-    Proteinuria >300
-    Hematuria: 50-100 red blood cells per high-power field
-    Anemia: hemoglobin of 8.1, hematocrit of 25.4%
-    Mean corpuscular volume 77
-    Iron levels <10
-    Total iron binding capacity 197
-    Ferritin level 68
-    D-dimer positive at 4.73
-    ESR elevated at 50
-    Chest x-ray: right-sided pleural effusion + patchy linear opacity at base of left lung – consistent with scar tissue
-    Chest CT scan: bilateral small pleural effusions (greater on the right than the left)
o    significantly enlarged axillary
o    subpectoral lymph nodes bilaterally
o    small pericardial effusion
-    Positive result for ANA 1:640, positive antibodies against ds-DNA
-    IgG titer of 300
-    Anti-Smith finding
-    Decreased complement level: C3 levels 46.2, C4 levels 5.3
-    Positive Coombs test
-    Hypoalbuminemia at 3.1
-    Negative lupus anticoagulant antibody finding
-    Biopsy: diffuse proliferative lupus nephritis class IV - moderate activity and no chronicity
o    Moderate interstitial inflammation

Differencial diagnosis:

-    Autoimmune disease:
-    Rheumatoid arthritis
-    IgA nephropathy
-    SLE

Diagnosis:

SLE

Treatment:

-          Oral corticosteroids
-          Mycophenolate mofetil

Prognosis:

-          Need for renal, rheumatological, and primary care follow-up
-          Incurable disease

 

Transcript