A 57-year-old female has required intubation and mechanical ventilation for hypoxaemic respiratory failure with symptoms of cough and dyspnoea that have been gradually progressive over 4 weeks. There is a diffuse bilateral infiltrate on her chest X-ray. She has a history of rheumatoid arthritis and is receiving treatment with methotrexate and prednisolone and has no previous history of respiratory disease.
a) List the likely differential diagnosis. (20% marks)
b) Briefly outline the specific management issues relating to diagnosis and treatment of this patient, excluding acute resuscitation. (80% marks)
This question is identical to Question 20 from the first paper of 2014.
List the likely differential diagnosis here is only worth only 20% which means that a table of this size would be completely unreasonable.
Specific management issues relating to diagnosis and treatment:
To exclude non-infectious causes:
To investigate infectious causes:
Reasonable steps to prevent deterioration:
Some empirical management to cover for the usual suspects:
If things are not going as planned (i.e. it's a week down the track and the patient is not getting better), a lung biopsy might be indicated. Apparently, it often identifies steroid-responsive pathology (Gerard et al, 2018), in which case the college's suggestion (massive doses of methylprednisolone) becomes relevant.
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