A 28-year-old woman presents to the emergency department with a 2-day history of sharp rig… — USMLE Step 2 CK

A 28-year-old woman presents to the emergency department with a 2-day history of sharp right-sided chest pain that worsens with deep inspiration. She also reports shortness of breath and generalized fatigue. She was diagnosed with systemic lupus erythematosus (SLE) three years ago and is currently prescribed hydroxychloroquine, though she admits to missing several doses recently. Her temperature is $38.1^\circ\text{C}$ ( $100.6^\circ\text{F}$ ), blood pressure is $122/78\text{ mm Hg}$ , pulse is $102/\text{min}$ , and respirations are $22/\text{min}$ . Physical examination reveals a pleural friction rub over the right lower lung field. Her wrists and metacarpophalangeal joints are tender and swollen bilaterally.

Laboratory studies are as follows:

Parameter	Value	Reference Range
Leukocytes	$3,400/\text{mm}^3$	$4,500-11,000/\text{mm}^3$
Hemoglobin	$10.8\text{ g/dL}$	$12.0-15.5\text{ g/dL}$
Platelets	$110,000/\text{mm}^3$	$150,000-400,000/\text{mm}^3$
TSH	$2.4\text{ }\mu\text{U/mL}$	$0.5-5.0\text{ }\mu\text{U/mL}$
Free T4	$1.2\text{ ng/dL}$	$0.9-1.7\text{ ng/dL}$

Arterial blood gas analysis on room air:

Parameter	Value	Reference Range
pH	$7.46$	$7.35-7.45$
pCO $_2$	$32\text{ mm Hg}$	$35-45\text{ mm Hg}$
pO $_2$	$88\text{ mm Hg}$	$75-105\text{ mm Hg}$
HCO $_3^-$	$22\text{ mEq/L}$	$22-28\text{ mEq/L}$

Chest radiography shows a small right pleural effusion with no pulmonary infiltrates. Electrocardiography shows normal sinus rhythm.

Which of the following is the most appropriate next step in the management of this patient?

Initiate systemic glucocorticoid therapyCevap
B
Administer intravenous piperacillin-tazobactam and vancomycin
C
Administer nebulized albuterol and ipratropium
D
Initiate levothyroxine supplementation
E
Administer intravenous sodium bicarbonate

Cevap

The most appropriate next step is to initiate systemic glucocorticoid therapy to treat the acute systemic lupus erythematosus (SLE) flare.

The correct action is to initiate systemic glucocorticoids. This patient is presenting with a classic acute flare of systemic lupus erythematosus (SLE) triggered by medication non-adherence. The flare is characterized by serositis (evident by pleuritic chest pain, pleural friction rub, and pleural effusion), polyarthritis, and active cytopenias. Because she has a moderate-to-severe manifestation (pleuritis causing significant respiratory distress/pain), systemic glucocorticoids (e.g., prednisone) are the most appropriate first-line therapy to quickly suppress the widespread autoimmune inflammation.

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Analyze the clinical presentation.

The patient has pleuritic chest pain, a pleural friction rub, fever, and polyarthritis in the setting of known SLE and medication non-adherence.

Identifying the cluster of symptoms helps categorize the acuity and etiology of the presentation.

Interpret the diagnostic data.

Laboratory results show characteristic SLE cytopenias (leukopenia, anemia, thrombocytopenia) and normal thyroid function. The ABG shows respiratory alkalosis due to pain-induced tachypnea. Chest radiography reveals a sterile-appearing pleural effusion without infiltrates.

Ruling out alternative life-threatening causes such as bacterial pneumonia, hypoxemic respiratory failure, or severe metabolic derangements is crucial before attributing symptoms solely to an autoimmune flare.

Determine the next step in management based on the diagnosis.

The diagnosis is an acute SLE flare with serositis (pleuritis). The appropriate intervention is immunosuppression with systemic glucocorticoids.

Moderate to severe SLE flares involving major organs or serosal surfaces require prompt reduction of inflammation to prevent tissue damage.

Anahtar Kavram

Patients with systemic lupus erythematosus (SLE) commonly experience acute flares characterized by serositis (e.g., pleuritis, pericarditis), polyarthritis, and cytopenias. In the absence of infection, moderate to severe flares should be managed acutely with systemic glucocorticoids.

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