,
13 tweets,
3 min read
Read on Twitter
1/Hey, #medtwitter, bust out your schemas - it's time for another CPSers tweetorial! #FOAMed #clinicalreasoning #medthread
2/A 46F presented with 2 weeks of diffuse abdominal pain, nausea and vomiting. Pause and reflect on how you’d approach her abdominal pain, and then check out this schema: clinicalproblemsolving.com/dx-schema-abdo…
3/On exam, her VS were T 36.2C BP 178/100 HR 82 and RR 16. She had sclerodactyly as well as shiny/thickened skin over her face, arms, and chest with telangiectasias. There was 2+ pitting BLE edema.
4/On further history, she had limited contact with healthcare but endorsed severe Raynaud’s phenomenon and arthralgias that began roughly 2 years prior. While you check out this picture (yes,yes, it’s not her…..sorry!), what is the most common cause of Raynaud's phenomenon? 
5/Primary Raynaud's syndrome (without a secondary condition) is way more common than secondary disease. Check out this schema for more: clinicalproblemsolving.com/dx-schema-rayn…
6/She had a BUN of 30 mg/dL and creatinine of 4.21 mg/dL. The hemoglobin was 10.1 and platelets were 104,000. The remainder of her labs were normal.
7/What information would be most helpful in supporting a diagnosis of acute kidney injury (AKI) over chronic kidney disease (CKD)?
8/While all of these can help support a diagnosis of AKI over CKD, previous creatinine measurements are the most reliable indicators of the time course of kidney injury.
9/Alrighty, back to the case, she had a previous creatinine measurement 3 months prior that was 0.8 mg/dL. She received 2L of IVF without improvement in her creatinine and a foley catheter was placed with minimal urine output.
10/Urinalysis had no proteinuria, RBCs or WBCs. A urine protein to creatinine ratio was mildly elevated. There were no dysmorphic RBCs, RBC casts, or WBC casts. An ANA was positive with a speckled pattern. Suspecting an intrarenal AKI, which localization is LEAST likely?
11/ Lack of albuminuria (protein on dipstick) makes glomerular injury the least likely. The absence of muddy brown casts or WBC casts does not dissuade from the possibility of tubular or interstitial injury. A relatively bland UA is also consistent with vascular intrarenal AKI.
12/A renal biopsy was performed and demonstrated normal glomeruli and interstitium. There was, however, intimal proliferation with obstruction of the lumen of the arcuate and interlobular arteries supplying the glomeruli.
13/What diagnosis are you most suspicious of? The answer,illness script, and more info to follow on Wednesday!
