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 A 50 yo male with long standing RA.....  



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Author13 Posts
  #1

case: A 50 yo male pt. with long standing Rheumatoid arthritis, with multiple jt. involvement, destructive in a wheel chair presents with abdominal distension,fatigue, breathlessness and new onset of sorethroat.
O/E.....pt. shows typical deformities of RA, Temp--38.5 F, febrile,RR-19/min, Pulse--100/min,BP--130/90mmHg. Pt. shows marked pallor, chest exam--normal,Abd---nontender, with a left hypochondriacal mass. Pt. is admitted for evaluation....Hct--24%, WBC--1020,Neutrophils-40%, lymphocytes--33%, BUN--43, Cr--1, Platelet--1,20,000, alb--3.5, Now, he was admitted and the 2nd day of admission, he developed fever, cough,and showed marked hypoxemia on ABG and was given O2. Which of the following is the least likely cause of his new onset respiratory demise?
a.Pseudomonas pneumonia
b.Staphylococcal pneumonia
c.ARDS
d.New onset pleural effusion
e.G-ve septicemia




  #2

i think c ARDS


  #3

Pseudomonas Pneumonia (least likely cause)


  #4

PEEEEEEEERFECT DPS.......... grin grin It, IS ARDS...........
Now, can u or anyone, tell me wat's goin on in this pt????? and y ARDS is least likely? :wink: grin


  #5

HI SMITHA...

I HAVE A THOUGHT ABOUT THIS PATIENT...

WAS HE ON METHOTREXATE OR IMMUNOSUPPRESIVE THERAPY...
DID HE SUBSEQUENTLY DEVELOPED NEUTROPENIA.........

IF THIS PATIENT HAD NEUTROPENIA THEN HE IS AT INCREASED RISK OF DEVELOPING VARIOUS PULMONARY INFECTIONS LIKE PNEUMONIAS AND ALSO SORE THROAT...

MAY BE THERE ARE NOT ENOUGH NEUTROPHILS TO CAUSE ALVEOLAR DAMAGE AND ARDS.....BUT I M NOT SURE ABOUT THIS.......


  #6

I M SURE THAT THIS PATIENT HAD FELTY'S SYNDROME.....

THENHE HAS THE CLASSIC TRIAD OF CHRONIC RA, SPLEENOMEGALY AND NEUTROPENIA

THERE IS DEFECTIVE FUNCTION AND NUMBER OF POLYMORPHONUCLEAR LEUCOCYTES IN FELTY'S SYNDROME .....SO MAY BE LESS LIKELY TO DEVELOP ARDS....... :lol: :lol:


  #7

That wa just BRILLLLLLLLLIANT shirish.......... =D> =D>
Yes, this pt. having FELTY'S SYNDROME, landed up in neutropenia, has no cells for ARDS................. sad sad grin
So, it's the least likely cause of his new onset respiratoty demise.....


  #8

how low should WBC (or PMN) count be in this case not to elicit inflammation? or rephrasing it,
is there any specific count that are siginificant for not eliciting ARDS?


  #9

as shirish mentioned above there is defective function as well as number both of polymorphonuclear cells in felty's syndrome....
plus this patient with neutropenia is more likely to develop septicemia and other options more than develop ards.....
i think smitha and shirish r right.....


  #10

Yes, shirish explained the option quite well.

Just curious, could you plz elaborate a little more on the differences in the pathophysiology (esp of marked hypoxemia), in this situation, between ARDS and other options mentioned.


  #11

How is hypoxemia differnet.....

Well ...ARDS is somewhat a symmetrical disease...or more like somewhat diffuse and the alveoli become filled with fluid....
Not different from pneumonia in whci hthe alveoli also become filled with fluid but in a less diffuse form...

This fluid occupying the alveoli reduces the diffusion across the membrane
But obviously the extensive involvement of the air spaces in ADS gives it its characteristic hypoxemia that is non responsive to High O2 therapy ....

Hope that explains it to an extent.....

Usually when someone mentions.... hypoxemia refractory to O2 treatment ...... the cause is a right to left shunt ...and ARDS is an intrapumonary shunt......


another thing...sometimes..... Pulmonary emboilus esp if large can cause refractory hypoxemia.....
Can u tell me why ? grin grin


  #12

Hello delusional.....
I guess the answer for ur q is in ur answer/xplanation u just gave, as far as i think!!!!!! grin
I guess, this large pulmonary embolus, can cause ARDS, which is an intrapulmonary shunt as u've just mentioned, and then, of course, it wud lead to refractory hypoxemia............. grin
Correct me if iam wrong!!!!!! sad


  #13

Yes Smitha ....correct grin

On a low level ..... PE causes bronchonstiction and atelactasis which impairs diffusion thus causing intrapulmonary shunting ...on a larger scale...ARDS ensues and causes the intrapulmonary shunting.....

All presenting as refractory hypoxemia ....

grin





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