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DwayneEMTP

Disease process scenario...

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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."

731210-thumb1.png

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 by DwayneEMTP

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What is his occupation.

Man, great question! But I don't have the answer. As well, they don't present race, which at first I thought might be relevant, but as I don't see it I'm guessing it's not. I've not read the answer to this scenario by the way.

But I'm going to take a stab based on experience...Above the knee amputation, hypertension, regular weed, alcohol, cigarette use, left one hospital AMA and went to another mid treatment (Guessing no narcs for pain at first hospital)....I'm going with homeless or home bound.

Dwayne

Edit. Also I only posted one picture, but both hands have near identical issues.

Edited by DwayneEMTP

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I am a active member of Medscape. I have posted scenarios from there before.

i have already read the entire article when it came to medscape and learned something, err I mean a lot. I had no idea what that lesion was but I do now and I had no idea that a disease process in the middle of the body can manifest itself in the hands,thumb joint.

Dwayne, good post and I will not answer any of the questions as I've already read the article and know the end result.

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I am a active member of Medscape. I have posted scenarios from there before.

i have already read the entire article when it came to medscape and learned something, err I mean a lot. I had no idea what that lesion was but I do now and I had no idea that a disease process in the middle of the body can manifest itself in the hands,thumb joint.

Dwayne, good post and I will not answer any of the questions as I've already read the article and know the end result.

Actually, this is a great post. I'm glad you gave a hint as to the multisystem issues involved.

Dwayne

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I went to the site and read the entire article so I am not going to answer but that is seriously crazy, I have found my new site of stalking medical info :)

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Would be nice to have a blood culture.

I'm going to go with infectious endocarditis. He almost meets Duke Criteria, but we don't have blood cultures on him yet. The painful nodes are Osler's Nodes and are caused by immune complexes. He has a fever, and while technically a third minor criteria is IV drug use, I'd throw in cellulitis with S. aureus cellulitis as fitting that. S. aureus is important. Tricuspid valve IE is limited to being infected with S. aureus and S. aureus is essentially limited to IV drug abuse. However, surgical site + S. aureus infection = bacterima. S. aureus is also unique in another fashion. IE normally requires some sort of damage to the cardiac valves, such as stenosis or regurg. Both of those cause jets to form which causes damage. From there, you get platelet and fibrin buildup on the valve. This leads to a nice little camping spot for bacteria. Additionally, the web of platelets and fibrin also makes it difficult for antibiotic penetration, which means the normal treatment length is something like 6 weeks IIRC.

Additional signs/symptoms I would expect to eventually develop includes a systolic murmur as the tricuspid is damaged as well as splinters in the nail beds which are called "Janeway lesions."

Edit:

2 quick things to note. I clicked through to the second page with IE. The only thing I Googled was the Duke criteria (by name, couldn't fully remember the criteria). Helpful link on Duke Criteria: http://www.medcalc.com/endocarditis.html Also, which is why I'm putting this in spoilers, but we covered IE in Cardio a few weeks ago.

Edited by JPINFV

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I decided not to click the spoiler and take a stab with my own half-baked idea... the diarrhea, fever, anorexia, weakness and malaise all point me towards a couple of ideas.

1: Immunodeficiency (Could be a malfunction of his normal state with no infectious case, could be HIV, you never know).

2: Leukemia, especially with weird pain in hands (bone pain and inflammation around joint capsules)

Too bad there isn't a blood count to look at as well... that would really be helpful... especially white cell counts. So on to the third idea that just occurred to me...

Hmm... could be a hyperreactive immune system responding to vestiges of a bacterial infection, attacking connective tissue (forming the nodules) and prompting the fever and pain... I wonder how recent the cellulitis was?

Wendy

CO EMT-B

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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.

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I decided not to click the spoiler and take a stab with my own half-baked idea... the diarrhea, fever, anorexia, weakness and malaise all point me towards a couple of ideas.

1: Immunodeficiency (Could be a malfunction of his normal state with no infectious case, could be HIV, you never know).

2: Leukemia, especially with weird pain in hands (bone pain and inflammation around joint capsules)

Too bad there isn't a blood count to look at as well... that would really be helpful... especially white cell counts. So on to the third idea that just occurred to me...

Hmm... could be a hyperreactive immune system responding to vestiges of a bacterial infection, attacking connective tissue (forming the nodules) and prompting the fever and pain... I wonder how recent the cellulitis was?

Wendy

CO EMT-B

Laboratory analysis reveals a hemoglobin level of 12.2 g/dL (122 g/L), hematocrit of 37.0% (0.37), a white blood cell count of 6.7 × 103/μL (6.7 × 109/L), a platelet count of 150 × 103/μL (150 × 109/L), a creatinine level of 1.15 mg/dL (101.66 μmol/L), a blood urea nitrogen (BUN) level of 13 mg/dL (4.64 mmol/L), and an erythrocyte sedimentation rate of 47 mm/hr. Electrocardiography reveals a normal sinus rhythm, with no ST- or T-wave abnormalities. The patient is given a normal saline bolus, ibuprofen, and morphine sulfate in the ED. The nodules on the patient's hands are pictured here (

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