Fever, abd pain in a patient on pred, mtx

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A 50s F with hx RA on methotrexate cc fever x 2-3 days.  She denies cough, sob, chest pain, dysuria, or flank pain.  She has epig / LUQ pain with nausea, vomiting x 1, no diarrhea.  She has no other pmh.  Her meds include pred, metformin, lantus, metoprolol, and simvastatin.  She has no psh.  On exam, she has HR 80, RR 14, BP 130 / 74, T 103, RA sat is 100.  Her exam is normal with minimal LUQ tenderness, if any.  She is obese.

What work-up do we do?

What is her treatment and dispo?

3 Comments

  • BC

    She’s immunosuppressed and febrile so shotgun the usual labs, CXR, and urine.

    Look at CBC to see if she’s neutropenic.

    She’s not tachycardic despite the fever (maybe due to beta blocker?) and c/o nausea/vomiting. Legionnaires?

    LUQ pain = splenomegaly? Can’t really tell on exam because she’s obese. Consider CT abd/pelvis? Can also rule out other bad abdominal pathology.

    I imagine she’ll be admitted + broad spectrum abx

  • Tonynap

    This lady gets a scan
    Considerations
    1. All the same things we consider in healthy patients i.E diverticulitis and particularly with the luq and fever pancreatitis
    2. She is immunosuperseded on prednisone/methotrexate with a chronic inflammatory condition which if she is also in NSAIDs puts her at risk for both perforating (stomach free wall rupture) or penetrating (retroperitoneal rupture-don’t get fooled by an small elevation in lipase if the patient looks sick; still get the scan.
    Plan: 2 liters ivfs reglan/pepcid/mso4/gastrograffin, chem looking for third spacing/lytes/lfts/lipase, CBC for white count, UA, and lactate.

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