Disease process scenario...

[Eydawn]

Well, there goes my top two differential diagnoses based on that leukocyte count...

Ok. I'm stuck. Autoimmune is what I'm thinking but beyond that I can't figure it out.

Bugger!

Wendy

CO EMT-B

[DwayneEMTP]

Actually Wendy, you'd be a better one to run this little shindig. I don't have the education to taunt you with s/s, but you might be able to lead some other folks on an interesting journey.

Whatcha think?

Dwayne

Ok well I had to Google a few things like the meds just to see what they were for but anyways.

Here is my idea.

Could it be Brown Recluse spider bites? The fever, pain, general malaise, weakness and diahrea sound an awful lot like the reaction to one.

The lesions on the hands, being two small nodules, sounds like a bite as well.

Being there are no other S&S of infection elsewhere and vitals seem within normal limits given his history. Also building on Dwayne's idea of homeless or home bound its logical. No history of IV drug use to me would rule out them being injection sites with bad needles. Also him leaving mid treatment from another hospital tells me he is not a pill popper.

I have had this bite 2 times before so I am also talking from experience LOL

If it really is a bite then the lesions would start to necros soon. It looks like they are about 2 to 4 days old as they haven't yet opened up.

Actually, I think your logic is really strong, but would it be likely that he would have been bitten in nearly the same location bilat?

Dwayne

[CSAR_MEDIC]

Ok so the meds are leading me to heart failure, if the pump is not pumping maybe there is an accumulation of an enzyme or protein leading to the joint Pn, With his heart compromised and the recent Hx of Staph I wonder if it could be pericarditis however with inflmation in the pericadiium I am pretty sure you would have diffuse ST elevation in all leads. I am researching the WBC counts now. This is a good one.

Fever is real low grade too, hmmm damn you dwayne !

Ok so the meds are leading me to heart failure, if the pump is not pumping maybe there is an accumulation of an enzyme or protein leading to the joint Pn, With his heart compromised and the recent Hx of Staph I wonder if it could be pericarditis however with inflmation in the pericadiium I am pretty sure you would have diffuse ST elevation in all leads. I am researching the WBC counts now. This is a good one.

I am wondering about the celuitous, typically this resolves without issue however with the comorbid factors of CHF and renal issues I wonder if that is causing a pooling if you will at the distal.

This scenario delivered to my email from Medscape.com. If you aren't familiar with them, I think you should be. Pretty interesting stuff on their site, plus they have a really good smart phone med app, as well as sending these cool scenarios to my email.

Note to new users and those with unusually small penises. The purpose of the scenarios is to walk through anatomy and physiology from the information that you already have in your head. This is not a test, it is a learning exercise. Googling your the answers prior to answering not only cheats you out of developing vital context links to this information in your head for use on scene, where Goggle can most times be scarce, but makes you look like a coward and cheater when you post your carefully edited, though dishonest response. Also, people can spot a Googled answer a mile away. I'm not saying that you shouldn't use Google to help in your investigation if you MUST, but don't post your findings unless you can explain them in your own words and justify them. Just saying. (Edit: for the record, I couldn't have diagnosed this in a million years. I just thought that the s/s were such that with the help of those here we would take a long and enjoyable walk through the body trying to tie them together.)

To those of you that choose to answer, please don't just list the name of a disorder in your post. Give those of us that might not be as smart as you the benefit of the logic tree that you followed to come to your diagnosis. Know what I mean? Thanks a bunch...

http://cme.medscape...._0&uac=150988SZ

"A 48-year-old man presents to the emergency department (ED) with a 10-day history of intermittent subjective fever and pain in his hands. He has also noticed 2 swollen and painful areas on his thumbs. Concurrently with the fever, he reports weakness, malaise, watery diarrhea, weight loss, anorexia, and intermittent vomiting. He denies having any cough, dyspnea, headache, chest pain, abdominal pain, hematemesis, or hematochezia. His medical history includes hypertension, deep venous thrombosis without a known coagulation disorder, nephrolithiasis, peptic ulcer disease, and a methicillin-resistant Staphylococcus aureus cellulitis. His surgical history includes a right leg above-the-knee amputation resulting from a gangrenous infection acquired during a natural disaster years ago. The leg healed well and without complications. He has no medical or seasonal allergies. The patient takes lisinopril, 20 mg daily; amlodipine, 5 mg daily; carvedilol, 25 mg daily; and ibuprofen as needed for pain. He is not currently taking any blood-thinning agents. The patient admits to occasional tobacco, cannabis, and alcohol use but denies injection drug use. He reports no remarkable family history. The patient had recently been admitted to another hospital, but he left before completing treatment and does not know his diagnosis."

On physical examination, his oral temperature is 97.8°F (36.6°C), pulse is regular and with a rate of 74 bpm, blood pressure is 151/90 mm Hg, and respiratory rate is 16 breaths/min. The patient is in mild distress due to pain from his hands. His sclerae are anicteric. The lungs are clear to auscultation, and the heart sounds are normal and without murmur, rub, or gallop. His abdomen is soft, nontender, and nondistended, with normal active bowel sounds and no hepatosplenomegaly. Examination of the hands reveals 2 discrete, tender nodules over the palmar aspect of the thumbs at the metacarpal-phalangeal joints bilaterally. The nail beds of both hands are pale, but his radial pulses are normal bilaterally. His right leg has a well-healed knee amputation site, with no signs of erythema or induration.

Edited November 6, 2010 by CSAR_MEDIC

[uglyEMT]

Sorry Dwayne missed the bilat part. I thought it was only on the hand in the picture. Then you would be right and it isnt a spider bite.

Ok now I am totally out of my element with this one. Time to call the ALS boys...

[DwayneEMTP]

Maybe this will help??What is the likely diagnosis?

Hint: Consider the history of fever; weakness; and tender, painful nodules on each thumb.Secondary syphilisInfectious endocarditisHistoplasmosisSystemic lupus erythematosus

[DwayneEMTP]

...Ok so the meds are leading me to heart failure,

With you so far... :-)

...if the pump is not pumping maybe there is an accumulation of an enzyme or protein leading to the joint Pn,...

Could you explain the logic you used to arrive at this hypothesis? I get where you're going but what protein or enzyme are you aware of that would cause such a symptom? And why the joints, particularly these specific joints?

...With his heart compromised and the recent Hx of Staph I wonder if it could be pericarditis however with inflmation in the pericadiium I am pretty sure you would have diffuse ST elevation in all leads.

Just pulling this out of my ass, but I would be surprised to have acute pericarditis with diffuse ST elevation that is asymptomatic. Perhaps not, just a thought. Yeah, I'm thinking I would likely have never gotten acute pericarditis secondary to Staph infection as a cause of thumb pain...I'm interested to hear your reasoning.

.Fever is real low grade too, hmmm

I didn't notice the fever. I see a description of 'subjective fever' but don't see a quantifiable value. What does the lack of fever do to your hypothesis?

.I am wondering about the celuitous, typically this resolves without issue however with the comorbid factors of CHF and renal issues I wonder if that is causing a pooling if you will at the distal.

Again, I'm not saying you don't have a point, but I would be surprised to see cellulitis with this presentation unilaterally, but bilat I would be very suspicious of a cellulitis differential. But again, I'm certainly no expert...

Thanks for playing man! sorry to have taken so long to respond....

Dwayne

[uglyEMT]

considering fever weakness I would think systemic infection. Nods on the hands bilat are a puzzle to me. Being his amputation site is not infected I would rule out gangreen or related illness.

MERSA infection could cause some sort of autoimmune reaction thus the general symptoms. Fever leads me to believe infection somewhere but without outward visable signs seems its an internal issue. Non of the meds listed sound like they treat MERSA or any kind of infection. Most except ibprofen sound cardiac related.

One thing that has me scratching my head is you said fever but an oral temp of 97.8 which wouldn't be feverish. Is he sweating and saying he is hot (cold sweats) or is his skin warm to the touch thus the fever finding? Might be withdrawl?

He has a DVT history so maybe something pulminary related. Could he be in late stage PE and the noduals are just a distractor? I know you said lung sounds were clear but is it a possiblity. The BP and pulse lead me to say no BUT.. stranger things have happened. I know I know dont see zebras through the horses.

Well I will leave it at that for know. Based on my knowledge and not googling anything I would say to my ED personel that he is showing S&S of an infection with a high possiblity of a pulminary component to it.

Let the higher medical authorities take this one.

Restock my rig and 10-8 back in service

Dwayne thanks for this. It is making me think more of how the whole body works together vs a single system. I cant wait to hear what this is and if I was in the right system. Thank you for making me think and not just load and go with a PCR stating general malaise (flu).

[DwayneEMTP]

considering fever weakness I would think systemic infection. Nods on the hands bilat are a puzzle to me. Being his amputation site is not infected I would rule out gangreen or related illness.

Awesome place to look for the origins of an infection. I'm not sure his afebrile status rules out those issues, I would think so, but I'm not sure, but I like the way your mind works.

MERSA infection could cause some sort of autoimmune reaction thus the general symptoms. Fever leads me to believe infection somewhere but without outward visable signs seems its an internal issue. Non of the meds listed sound like they treat MERSA or any kind of infection. Most except ibprofen sound cardiac related.

Agreed, but it did say, didn't it, that he was started on antibiotics and left AMA? Perhaps that was in the solution.

...One thing that has me scratching my head is you said fever but an oral temp of 97.8 which wouldn't be feverish. Is he sweating and saying he is hot (cold sweats) or is his skin warm to the touch thus the fever finding? Might be withdrawl?

Right! What physiologic condition might cause him to sweat and feel cold but not produce a fever? (General question, not related to the answer)

...He has a DVT history so maybe something pulminary related. Could he be in late stage PE and the noduals are just a distractor? I know you said lung sounds were clear but is it a possiblity.

I guess it could be..not sure.

...The BP and pulse lead me to say no BUT.. stranger things have happened. I know I know dont see zebras through the horses.

On the contrary, I believe that the experience on an ambulance conditions you to horses, but that it's the professionals duty to catch the zebras.

...Well I will leave it at that for know. Based on my knowledge and not googling anything I would say to my ED personel that he is showing S&S of an infection with a high possiblity of a pulminary component to it.

What findings would lead you to give that report?

Normotensive, afebrile, other than pain scale all vitals well within acceptable limits, right?

Let the higher medical authorities take this one.

Man, I think you're doing fine!! If this was my issue I'd hope that you'd run it. You may not come up with the answer, but you're asking all of the right questions, and that's vital. For the record, there aren't a dozen people on this board that could come up with the answer without cheating, and I'm certainly not one of them. And there are, as you can see, very few that are willing to take a shot at something so friggin' weird simply for the mental exercise. I have nothing but respect for everything that I've seen from you in past months. Good on you brother.

I friggin' hate your screen name though. It doesn't suit you. You need to change it to something that is more likely to cause people come to you as a mentor instead of think that you're a goofy kid, as the first is a good thing and I've not seen any sign that the second is accurate. See?

Dwayne thanks for this. It is making me think more of how the whole body works together vs a single system. I cant wait to hear what this is and if I was in the right system. Thank you for making me think and not just load and go with a PCR stating general malaise (flu).

You're welcome brother, though I've learned much more from you in this thread than I learned from posting the question.

Dwayne

[JPINFV]

Redacted

Edited November 8, 2010 by JPINFV

[DwayneEMTP]

Redacted

How come? I was excited when I saw that you'd posted here!! I'm so ridiculously far out of my league that it's no longer funny.

Could use some help from the smart folks...

Dwayne