Interesting case
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Interesting case
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I saw a case in my GP surgery that puzzled me today . 63 yo care worker. Unwell for about 6 weeks, some loss of appetite. Occasional episodes of abdominal pain when he feels 'faint' and has to stop. T
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Interesting case
posted at 20/9/2012 10:57 PM BST
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
I saw a case in my GP surgery that puzzled me today . 63 yo care worker. Unwell for about 6 weeks, some loss of appetite. Occasional episodes of abdominal pain when he feels 'faint' and has to stop. These episodes last a few minutes and are infrequent.. In the past 2 weeks he has developed a non itch blotchy asymetrical rash on his fore arms, the rash starts as very small spots that then grow to the size of an old penny over the course of a day. The previous evening his wife came home from work and found him talking in a confused and what he described as a 'delerious ' manner. He is usually well and does not attend often. He is on no medication. He does not drink alcohol or smoke cigarettes. He has a pmh of traumatic loss of vision in left eye as a child. On examination he was afebrile, plethoric facial complexion. Pulse 76 regular bp 135/85 breath sounds vesicular,heart sounds normal, no murmurs, irregular blotchy rash on forearms left more than right . Abdomen soft , no abnormal masses felt. His only useful right eye reacted normally to light and accomodation, fundi normal. I could find no abnormal neurological signs. I checked his blood sugar which was normal I did what I suppose most Doctors do when they dont know he diagnosis and organised blood tests. Fbc, U and es Lfts immunoglobulins CRP and plasma viacosity as well as a few other blood tests and arranged for a Chest X ray. I will bring him back next week to see one if my partners who is the ' Mycroft' of the practice. My very tentative provisional diagnosis is an autoimmune disease. Any suggestions? Sorry about typos, no spell checker on ipad |
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Re: Interesting case
posted at 21/9/2012 5:37 PM BST
on bmj.com
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Posts: 1178
First: 19/4/2010 Last: 21/5/2013 |
Rash + delerium? Vasculitis - PV should be up Chronic infection - PV and or CRP should be up. No harm in a TPHA in these situations. Cancer - PV might be up, might end up going for a CT rule-out-o-gram? Could be paraneoplastic delerium, with a cutaneous manefestation of malignancy. Could you feel a spleen? No new drugs? Unlikely anyway. Keep us abreast. I'm interested in the PV, for sure. DEFINITELY worth a CXR. |
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Re: Interesting case
posted at 21/9/2012 6:41 PM BST
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
Thanks. Spleen not felt. I should have done WR (TPHA), and I have warned the Doctor who sees him next week that this blood test has not been done. I am concerned that a neoplastic disease may present. He has lost about 3 kg in weight in the 6 weeks he has been unwell. When I saw him he was not acutely ill and was mentally quite normal. I will try to post in a week or so when the diagnosis may be evident. |
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Re: Interesting case
posted at 22/9/2012 7:15 AM BST
on bmj.com
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Posts: 3045
First: 27/3/2012 Last: 20/5/2013 |
The clinical presentation might point towards a malignancy or it may be a manifestation of falciparum malaria although he is afebrile but showing altered level of consciousness & has erythematous lesions over both forearms. |
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Re: Interesting case
posted at 22/9/2012 10:40 PM BST
on bmj.com
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Posts: 339
First: 17/12/2011 Last: 15/5/2013 |
He has been in Thailand but not since February. He was in the Canary Islands in early June. I think Malaria unlightly I only see about one or two a year in my inner City UK practice, Most Malaria cases I see hve been working in central Africa. Although the last case of Malaria that I saw had been on round the world trip and had been swimming in a tributary of amazon a week or so before, so that diagnosis was not too dificult. Blood test should be available on Monday. I will probably go into work on Sunday to check path reports and other paper work. I expect raise CRP and raised Plasma Viscosity, his LFTs and U and Es may be abnormal. No recent changes in his working enviroment. |
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Re: Interesting case
posted at 25/9/2012 5:16 PM BST
on bmj.com
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Posts: 1
First: 25/9/2012 Last: 25/9/2012 |
In Response to Interesting case: I saw a case in my GP surgery that puzzled me today . 63 yo care worker. Unwell for about 6 weeks, some loss of appetite. Occasional episodes of abdominal pain when he feels 'faint' and has to stop. These episodes last a few minutes and are infrequent.. In the past 2 weeks he has developed a non itch blotchy asymetrical rash on his fore arms, the rash starts as very small spots that then grow to the size of an old penny over the course of a day. The previous evening his wife came home from work and found him talking in a confused and what he described as a 'delerious ' manner. He is usually well and does not attend often. He is on no medication. He does not drink alcohol or smoke cigarettes. He has a pmh of traumatic loss of vision in left eye as a child. On examination he was afebrile, plethoric facial complexion. Pulse 76 regular bp 135/85 breath sounds vesicular,heart sounds normal, no murmurs, irregular blotchy rash on forearms left more than right . Abdomen soft , no abnormal masses felt. His only useful right eye reacted normally to light and accomodation, fundi normal. I could find no abnormal neurological signs. I checked his blood sugar which was normal I did what I suppose most Doctors do when they dont know he diagnosis and organised blood tests. Fbc, U and es Lfts immunoglobulins CRP and plasma viacosity as well as a few other blood tests and arranged for a Chest X ray. I will bring him back next week to see one if my partners who is the ' Mycroft' of the practice. My very tentative provisional diagnosis is an autoimmune disease. Any suggestions? Sorry about typos, no spell checker on ipad Posted by Pat Lush Dear Pat, Can you please describe the rash a bit more?whether raised,painful??mucosal involvement?Do you have a snap of the rash at all? was urine checked? I am thinking in the line of HSP...need more info on bloods as well... SN |
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