December Case 1 (Full Version)

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Dr.Wagner -> December Case 1 (December 6, 2007 11:41:08 AM)

25 year old male presents from his Primary Care Physician office with a diagnosis of "polyarthralgia" and fatigue.  He says "my family doc didn't really even examine me".
He notes for the past month he has had worsening joint pain and decreasing appetite.  "Man, a whole bunch of stuff has been going wrong, I feel like I am 80". 
He has an envelope of tests that he has brought with him





buckeye -> RE: December Case 1 (December 6, 2007 12:04:21 PM)

Could be a wide range of issues - systemic disease, metabolic, or infection come to mind. What are the various test results in the envelope. What is his appearance? Vital signs?



buckeye -> RE: December Case 1 (December 6, 2007 12:06:17 PM)

Any skin lesions suggestive of insect bites? Any exposure to chemicals?



ehanso -> RE: December Case 1 (December 6, 2007 12:24:45 PM)

Lymes' Disease



Shill -> RE: December Case 1 (December 6, 2007 1:45:25 PM)

What does he do for a living/hobbies?  Is he married or single, has he traveled out of the country recently?  What are his vitals and labs showing?  Any history of depression or mental illness or SAD?  What is the "bunch of stuff" that has been going wrong?  How does he describe his fatigue?  What makes this unusual compared to his prior status?



jma -> RE: December Case 1 (December 6, 2007 9:34:47 PM)

Does he have a mark on the body, indicative of a rash? What from the mutlitude of tests that were done, caught your eye?



bonez -> RE: December Case 1 (December 7, 2007 1:21:12 AM)

Well he is in the right age range for several things. Many arthritides have accompanying anemia which might explain the joint pain and fatigue. The onset is abrupt and might not support those conditions. Is there more info labs physical exam weight loss familial Hx. Recent travel out of the US to say tropical countries?
Let's have it Doc.



Dr.Wagner -> RE: December Case 1 (December 7, 2007 8:29:45 AM)

"I just have been having sooo many problems!"  "For the past 2 weeks I can barely go up and down steps, last month my ankles were killing me and the month before that it was my elbows!...I feel like I am 80"
"Then I got this weird 'strep throat thing', except my throat didn't feel all that bad, it was really my mouth"...that happened about 2 monts ago, it still comes and goes"  "Just so much bad luck I can't even tell you!"

Vitals
HR 80, resp 14, temp 98.9, o2 100%

CBC:
wbc 9
hgb 14
hct 35
plt 220

BMP
na 140
k 4
cl 108
co2 28
cr 1
bun 18
gluc 102

ESR 50

knee xray "no acute disease or pathological process"








buckeye -> RE: December Case 1 (December 7, 2007 9:28:10 AM)

Any thyroid tests?



ehanso -> RE: December Case 1 (December 7, 2007 12:08:41 PM)

What test is done for mononucleosis?



Shill -> RE: December Case 1 (December 7, 2007 2:54:34 PM)

So Sed rate is way up, and Crit is somewhat low. Are these the only abnormal results?   I have no idea what this means, but I will guess acquired hemolytic anemia. 



steve -> RE: December Case 1 (December 7, 2007 3:48:14 PM)

ESR being so elevated doesnt mean much on its own but in light of his history I would be suspicious of sinister pathology like lymphoma or rheumatic conditions.  



Dr.Wagner -> RE: December Case 1 (December 7, 2007 5:31:23 PM)

Mono test negative




wooooo -> RE: December Case 1 (December 7, 2007 5:47:29 PM)

any RA profile



jimptdpt -> RE: December Case 1 (December 7, 2007 6:09:54 PM)

Since he's 25 y/o and the throat thing made me think.  I was thinking some type of STD,  Herpes or Gonorrhea. 



Dr.Wagner -> RE: December Case 1 (December 7, 2007 9:18:50 PM)

"oh yeah...I had the WORST eye pain...I had to go to the ER, but all they said I had was uveitis...not a whole lot to treat"

I brought a picture of my mouth sore...




[image]local://2287/0CC71789D4F747BC8D95F23E89A76386.jpg[/image]



wooooo -> RE: December Case 1 (December 7, 2007 10:24:21 PM)

Reiter's syndrome



Dr.Wagner -> RE: December Case 1 (December 8, 2007 10:56:58 AM)

Oh yes...and I have these painful leg veins...(nice one wooooooo...but just one more thing)

"and uh...sores on my genitals, that I never told my doctor about...kind of embarassing"







[image]local://2287/4A117BCA28BD4636B4437EA12D11AF4C.gif[/image]



bonez -> RE: December Case 1 (December 8, 2007 12:08:24 PM)

Well the high ESR and eye issues point to Behcet's syndrome. With his vascular lesions he will need treatment. Maybe thalidomide will resurface to save the day?



wooooo -> RE: December Case 1 (December 8, 2007 12:17:14 PM)

With the vascular lesions, I have to go with Behcet's syndrome also.



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