Sunday, August 24, 2008

Case 16

A 67 year old woman with history of rheumatoid arthritis presented to the emergency department with increasing anorexia, nausea and vomiting. 4 weeks ago she had developed an itchy, erythmatous rash predominately over her trunk. This had then diminished over a period of one week. In addition she had stopped passing urine.

She had a long history of rheumatoid arthritis, and used non-steroidal anti-inflammatory drugs to control her symptoms. She did not drink alcohol, never smoked cigarette. She lives at a nursing home .She is unable to feed herself secondary to severe deformities of the small joint of her hands. She is confined to a wheelchair because of her arthritis.

On physical exam, she is afebrile, blood pressure 190/102 mm    Hg, pulse 82 /min, respiratory rate 18/min, her jugular venous pulse is elevated. Skin exam shows multiple excoriations over her trunk and extremities. Lung exam reveals bilateral. Lower extremities exam reveals moderate dependent edema. And there are obvious rheumatoid deformities in both hands. The rest of the physical exam is normal.


WBC 12 x 10/l, Hemoglobin 9 g/dL, , Platelets 202 x 10/l, Sodium 134meq/L
, Potassium 9.1meq/L, Chloride 98meq/L, Bicarbonate 12 meq/L, Blood urea nitrogen 47mg/dL, Serum Creatinine 6.1 mg/dL, plasma glucose 160 mg/dL. Urine analysis shows protein (+).there was 1-2 RBC /hpf.16 wbc/hpf and 6 granular and white cells casts/hpf, and no bacteria.

Renal ultrasonography shows no evidence of obstruction, and the kidneys size within normal range.

Q- What is the diagnosis?

Q What are the best next 2 steps in management

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