What is the appropriate management for a 52-year-old female presenting with chest pain, shortness of breath, right-sided pleuritic chest pain, bilateral inspiratory crackles, swollen small joints, and limited finger mobility?

Management of Suspected Rheumatologic Disease with Cardiopulmonary Involvement

This patient requires immediate emergency department transfer by EMS for urgent evaluation of life-threatening cardiopulmonary complications, with priority exclusion of pulmonary embolism, acute coronary syndrome, and pericarditis, followed by rheumatologic workup for likely connective tissue disease (most consistent with rheumatoid arthritis with extra-articular manifestations). 1

Immediate Life-Threatening Conditions to Exclude

Pulmonary Embolism (Highest Priority)

• The combination of pleuritic chest pain, dyspnea, bilateral crackles, and potential underlying inflammatory disease places this patient at high risk for PE 1
• PE presents with dyspnea, pleuritic chest pain, tachycardia, and tachypnea in >90% of cases 1, 2
• Obtain ECG within 10 minutes of ED arrival to assess for signs of right heart strain 1
• Measure cardiac troponin immediately upon presentation 1
• Order CT pulmonary angiography (CTPA) as the definitive diagnostic test for hemodynamically stable patients with high clinical suspicion 1, 2

Acute Coronary Syndrome

• Although right-sided stabbing pain is less typical, ACS can present with atypical symptoms, particularly in women 1, 3
• The presence of dyspnea and bilateral crackles raises concern for ACS with acute heart failure 1
• ECG must be obtained and reviewed within 10 minutes of arrival 1
• Cardiac troponin should be measured as soon as possible 1
• Critical pitfall: Sharp or stabbing pain does NOT exclude cardiac ischemia 3, 2

Pericarditis

• Sharp, pleuritic chest pain that worsens with deep breathing is characteristic of pericarditis 1, 4, 2
• Look for widespread ST-elevation with PR depression on ECG 4, 2
• Auscultate for pericardial friction rub (biphasic sound indicating pleural inflammation) 1, 2
• Obtain transthoracic echocardiography to assess for pericardial effusion 4, 2

Pneumothorax

• Unilateral pleuritic pain with dyspnea requires assessment for decreased breath sounds unilaterally 1, 3, 2
• Chest radiography will identify pneumothorax 1, 2

Rheumatologic Diagnosis: Rheumatoid Arthritis with Pulmonary Involvement

Clinical Presentation Consistent with RA

• Small joint swelling with limited finger mobility is pathognomonic for inflammatory arthritis, most commonly rheumatoid arthritis 3
• Bilateral inspiratory crackles suggest interstitial lung disease, which occurs in 10-20% of RA patients 5
• Pleuritic chest pain may indicate pleural effusion or pleuritis, both extra-articular manifestations of RA 2, 5

Pulmonary Manifestations of RA

• Interstitial lung disease presents with bilateral crackles and dyspnea 5
• Pleural disease (effusion or pleuritis) causes pleuritic chest pain 2, 5
• Pulmonary nodules and organizing pneumonia are less common manifestations 5

Diagnostic Algorithm

Phase 1: Emergency Department Evaluation (First 30 Minutes)

1. Obtain 12-lead ECG within 10 minutes to identify STEMI, pericarditis patterns, or PE signs 1
2. Measure cardiac troponin immediately to exclude myocardial injury 1
3. Order chest radiography to evaluate for pneumothorax, pneumonia, pleural effusion, interstitial lung disease, or cardiomegaly 1, 2
4. Perform focused cardiovascular examination checking for tachycardia, hypotension, pulse differentials, decreased breath sounds, or friction rub 1

Phase 2: Risk Stratification for Pulmonary Embolism

• Use validated clinical decision rules (Wells score or Geneva score) to determine pretest probability 1, 2
• If low-to-intermediate probability, obtain D-dimer with age-adjusted cutoffs 1, 2
• If high probability or positive D-dimer, proceed directly to CTPA 1, 2

Phase 3: Rheumatologic Workup (After Exclusion of Emergent Causes)

• Complete blood count with differential (assess for anemia of chronic disease, thrombocytosis) 5
• Erythrocyte sedimentation rate and C-reactive protein (markers of inflammation) 5
• Rheumatoid factor and anti-cyclic citrullinated peptide antibodies (diagnostic for RA) 5
• Comprehensive metabolic panel (assess renal function before NSAID use) 5
• High-resolution CT chest if interstitial lung disease suspected on plain radiography 5

Critical Management Decisions

Immediate Transport Indications

Transport urgently to ED by EMS if any of the following are present: 1, 3

• Age >52 years with dyspnea and pleuritic chest pain (high-risk features) 1
• Bilateral crackles suggesting pulmonary edema or interstitial process 1
• Inability to perform activities of daily living (cannot bend fingers) 1
• Any ECG abnormalities suggestive of ischemia or pericarditis 1

Office Setting Management

• Do NOT delay transfer for troponin testing in office settings 1
• If ECG unavailable in office, refer immediately to ED 1
• Call EMS rather than having patient self-transport 1

Treatment Priorities

Pre-Hospital/Initial ED Management

• Administer oxygen to maintain SpO2 >90% 1
• Establish IV access and initiate crystalloid hydration 1
• Consider aspirin 162-325 mg (chewable or water-soluble) if ACS suspected and no contraindications 1
• Provide analgesia with opiates if severe pain present 1

Definitive Management Based on Diagnosis

• If PE confirmed: Initiate anticoagulation with therapeutic-dose heparin or low-molecular-weight heparin, transition to warfarin (target INR 2.0-3.0) for 6-12 months 6
• If pericarditis confirmed: NSAIDs plus colchicine; consider steroids for refractory cases 4, 2
• If RA with pulmonary involvement: Urgent rheumatology consultation for disease-modifying antirheumatic drug (DMARD) initiation 5

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology - 7% of patients with palpable tenderness have ACS 2
• Never use nitroglycerin response as a diagnostic criterion - relief does not confirm or exclude myocardial ischemia 1, 2
• Never assume sharp, pleuritic pain excludes cardiac ischemia - 13% of ACS patients present with pleuritic pain 2
• Never delay imaging for suspected PE based on D-dimer alone in high-risk patients 1, 2
• Never discharge patients with unexplained bilateral crackles without definitive diagnosis 1, 5

Disposition

Admit to monitored bed or intensive care unit for patients with confirmed PE, ACS, pericarditis with effusion, or severe interstitial lung disease 1. Rheumatology consultation should be obtained within 24 hours for confirmed inflammatory arthritis with pulmonary involvement 5.