What's wrong with this patient?
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What's wrong with this patient?
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At the weekends I cover our high dependency unit, the chest unit, and also the infectious diseases unit. This weekend I found a very interesting patient, with an interesting constellation of sym
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Forums » Open clinical » General clinical » What's wrong with this patient?
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What's wrong with this patient?
posted at 28/6/2012 11:33 AM BST
on bmj.com
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Posts: 1213
First: 19/4/2010 Last: 14/6/2013 |
At the weekends I cover our high dependency unit, the chest unit, and also the infectious diseases unit. This weekend I found a very interesting patient, with an interesting constellation of symptoms, signs, and results. I've been cogitating all week, and I think I have at least one diagnosis, but I can't explain everything. I thought I might tap into the collaborative knowledge of D2D to try to get more answers.... And it's a fun game. To start off. He presents with a slightly swollen, red-ish area on his left shin. He feels tired, but not desperately unwell. He's very tanned, has a slightly swollen abdomen, and is apyrexial. You can ask for history, examination findings, and results of tests. Game on.
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Re: What's wrong with this patient?
posted at 29/6/2012 10:40 PM BST
on bmj.com
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Posts: 28
First: 25/9/2011 Last: 7/6/2013 |
In Response to What's wrong with this patient?: If he is an in-patient I presume he must be more unwell than your brief description OR he is thought to be contagious hence the need for admission...so what precipitated the admission? What were his presenting sympmtoms/complaints? Did he have a sore throat to suggest possible Erythema nodosum? Does his "tan" lead us to think adrenal insufficiency or Haemochromatosis or has he simply just come back from some hot climate and we are looking at some overseas acquired, possibly tropical disease. The possibility of some bite related disease comes to mind, Lyme disease even. So, where has he just returned from in the last say 6 weeks? At the weekends I cover our high dependency unit, the chest unit, and also the infectious diseases unit. This weekend I found a very interesting patient, with an interesting constellation of symptoms, signs, and results. I've been cogitating all week, and I think I have at least one diagnosis, but I can't explain everything. I thought I might tap into the collaborative knowledge of D2D to try to get more answers.... And it's a fun game. To start off. He presents with a slightly swollen, red-ish area on his left shin. He feels tired, but not desperately unwell. He's very tanned, has a slightly swollen abdomen, and is apyrexial. You can ask for history, examination findings, and results of tests. Game on. Posted by DundeeChest |
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Re: What's wrong with this patient?
posted at 30/6/2012 12:56 AM BST
on bmj.com
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Posts: 347
First: 17/12/2011 Last: 18/6/2013 |
How old is patient, how long has he had the symptoms of the reddish area on his shin, his abdominal swelling his tanned complexion and his tiredness? has he been abroad , recently? What is his job. The shin rash is only on his left leg so I presume it is not erythema nodosum as I would expect this and other rashes such as henoch schonlein purpura to be bilateral. I agree that the tiredness makes one think of addisons disease also this is often thought of but rare. Is his bp low, does it fall on standing up, is his pulse rate slow or fast? As doctors we tend to do tests if we think we have a diagnosis and also if we dont know the diagnosis! Some time the result of the Medical consultation is that ' we wanted to check that you did not have a serious disease and the test shows that you do not have that disease , so we dont know what is wrong with you , but we dont think it is anything serious , so go back to see your GP if it gets worse'. I presume his 'routine' blood test are normal and that he is not hypothyroid, diabetic uraemic or anaemic, are his urine 'stick tests' normal? What medicines if he on, one of my thought with most patient is, could the illness be iatrogenic? The diagnosis is usually 80 percent in the history so we need more history. I have my appraisal in about 2 weeks ( I dont like appraisal), so DundeeChest may use this case to talk through with my appraiser? I hope I have not missed a obvious diagnosis. Sorry for typos, no spell checker on I pad |
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Re: What's wrong with this patient?
posted at 30/6/2012 8:13 PM BST
on bmj.com
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Posts: 3059
First: 27/3/2012 Last: 13/6/2013 |
It would have been better if a quality photograph of the above patient would have been posted to diagnose the condition. Otherwise it seems worthless to comment on a patient without personal examination. |
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Re: What's wrong with this patient?
posted at 30/6/2012 8:35 PM BST
on bmj.com
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Posts: 1213
First: 19/4/2010 Last: 14/6/2013 |
Right. Sorry for the slight delay in response, I've been out and about all day. So yes, obviously more information is required. As I tell all the students - it's all in the history. So here's the answers to your excellent questions. If he is an in-patient I presume he must be more unwell than your brief description OR he is thought to be contagious hence the need for admission...so what precipitated the admission Not massively unwell, actually. He complained of a painful let calf. The medical admissions unit felt it was cellulitis, so he came to ID. Examination of his leg shows venous eczema, and no active cellulitis. What were his presenting sympmtoms/complaints? Did he have a sore throat to suggest possible Erythema nodosum? His complaint was the sore leg. No sore throat. Leg signs are not EN. Does his "tan" lead us to think adrenal insufficiency or Haemochromatosis or has he simply just come back from some hot climate and we are looking at some overseas acquired, possibly tropical disease. He says he's always been tanned. His iron, transferrin and his ferritin, for that matter, are normal. He has just returned from Turkey, where it was 46 degrees, but not strictly tropical. The possibility of some bite related disease comes to mind, Lyme disease even. So, where has he just returned from in the last say 6 weeks? He does have a couple of what look like insect bites on his left lower abdominal wall, and one on his chin. He thinks they were 'mosquito bites'. There's no evidence of erythema chronicum migrans, but there is a 2cm lesion on his right upper thigh, which looks a little bit like an eschar, to my respiratory eyes. No history of a tick bite, though. On to Lush. How old is patient, how long has he had the symptoms of the reddish area on his shin, his abdominal swelling his tanned complexion and his tiredness? He's in his mid 40s. The red area was there before his holiday, but he's not sure how long. So at least a month. He has always been tanned, since childhood, he says. The adbominal swelling has been there since he got back from Turkey a week ago. He's had something similar before, about 10 years ago. His tiredness has been for about 6 weeks. has he been abroad , recently? Turkey, 3 weeks ago. What is his job. Builder. The shin rash is only on his left leg so I presume it is not erythema nodosum as I would expect this and other rashes such as henoch schonlein purpura to be bilateral. I agree that the tiredness makes one think of addisons disease also this is often thought of but rare. His U&Es are plum normal. And I checked his random cortisol anyway, and it's normal. Is his bp low, does it fall on standing up, is his pulse rate slow or fast? Normotensive. No postural drop. HR is 90 - 100, sinus rhythm. I presume his 'routine' blood test are normal and that he is not hypothyroid, diabetic uraemic or anaemic, are his urine 'stick tests' normal? "Routine" tests are normal, apart from a slightly raised Bilirubin (31) and an ALT of 200. Alk Phos is 130. TFTs normal. BM normal. Hb normal. He's slightly lymphopaenic, lymphocytes are 0.9. What medicines if he on, one of my thought with most patient is, could the illness be iatrogenic? Not on any medication at all. The diagnosis is usually 80 percent in the history so we need more history. Indeed, and we're getting more history bit by bit here. Which is great! I shall tease you with some more tidbits I picked up on first meeting him. He was told 10 years ago that he had alcohol related hepatitis. He's been abstinate of alcohol since then. He developed vitiligo 6 weeks ago, on both hands, distal extremities of all fingers. There's no significant family history: both his parents are still alive, but have had MIs. His appetite is normal, he has not lost weight recently. Does anyone want to request any interesting tests? |
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Re: What's wrong with this patient?
posted at 1/7/2012 2:55 PM BST
on bmj.com
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Posts: 347
First: 17/12/2011 Last: 18/6/2013 |
Interesting, yes measure serum iron , also probably autoimmune profile. I would probably ask for ultra sound examination of his abdomen. Haemochromatosis might explain the tanned complexion but, would it explain the slightly swollen, red-ish area on his left shin ? |
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Re: What's wrong with this patient?
posted at 1/7/2012 7:49 PM BST
on bmj.com
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Posts: 1213
First: 19/4/2010 Last: 14/6/2013 |
In Response to Re: What's wrong with this patient?: Interesting, yes measure serum iron , also probably autoimmune profile. I would probably ask for ultra sound examination of his abdomen. Haemochromatosis might explain the tanned complexion but, would it explain the slightly swollen, red-ish area on his left shin ? Posted by Pat Lush Excellent. Iron is normal. ANA and ENA are normal. ANCA negative. Any other "autoimmune" tests, you'd like? USS abdomen: ascites, slightly enlarged, hyperechoic liver, consistent with alc hep, as previously. |
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