Exams and Tests

Medical evaluation in the emergency department

The nature of the medical evaluation in an emergency department depends on the person's complaint or problem. The goal of the emergency physician is to decide whether there are acute concerns on top of a chronic disease such as lupus. For someone without a known diagnosis of lupus, the doctor will evaluate but likely never provide a primary diagnosis of lupus unless there are clear and unmistakable features. Evaluation of chronic (not acute) diseases is done in a medical office setting.

The vast majority of blood tests looking for specific markers for lupus do not return results for several days, so definitive blood tests do not occur on the spot. However, certain tests to assess the possibility of organ damage including some blood and urine tests, imaging studies, and heart tracings will allow the doctor to assess for acute disease if someone with lupus seeks treatment in an emergency department.

The job of the emergency doctor is to address, evaluate, and treat acute issues and then refer the person to more appropriate specialists for further assessment and evaluation.

Criteria for diagnosing lupus

The diagnosis of lupus is a clinical one made by observing symptoms. Lab tests provide only a part of the picture. The American College of Rheumatology has designated 11 criteria for classification. To be classified as having lupus, a person must have 4 or more of these criteria:

• Malar rash: This is a "butterfly-shaped" red rash over the cheeks below the eyes. It may be a flat or a raised rash.
  
  
• Discoid rash: These are red, raised patches with scaling of the overlying skin. A subgroup of patients have "discoid lupus" with only skin involvement and do not have systemic lupus erythematosus. All patients with discoid lupus should be screened for systemic involvement.
  
  
• Photosensitivity: A rash develops in response to sun exposure. This is not to be confused with heat rash that develops in body folds or moist areas of the body with exposure to heat.
  
  
• Oral ulcers: Painless sores in the nose or mouth need to be observed and documented by a doctor.
  
  
• Arthritis: The arthritis of lupus usually does not cause deformities of the joints. Swelling and tenderness must be present.
  
  
• Serositis: This refers to an inflammation of various "sacs" or membranes that cover the lung, cover the heart, and line the abdomen. Inflammation of these tissues causes severe discomfort in the areas affected.
  
  
• Kidney disease: There is persistent loss of protein in the urine, or a microscopic analysis of the urine demonstrates inflammation of the kidneys.
  
  
• Neurological disorder: This can present as seizures or as a primary psychiatric disorder. 
  
  
• Blood disorder: Low blood counts of various blood components are known to occur.
  
  
• Immunologic disorder: This requires special laboratory testing for specific markers of disease in lupus. These tests include antibodies to DNA, a nuclear protein (Sm), or phospholipids (which includes the falsely positive test result for syphilis). The presence of these and other antibodies that can react with the body's own tissues is why lupus is called an autoimmune disease. 
  
  
• Positive antinuclear antibody: A more general marker in the blood for the presence of an autoimmune disease, these "ANA" levels increase with age, thereby somewhat increasing the rate of an incorrectly positive test as a person gets older. The ANA test is most useful when the result is negative, which essentially rules out the diagnosis of SLE, since up to 98% of people with lupus have a positive ANA test result.