Disease process scenario...

[JPINFV]

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

My original comment was, "Why not non-resistant staph instead of MRSA if you're looking at infection?" While it doesn't have to be resistant staph for this, the specific case includes MRSA cellulitis, which was why I redacted it. If the cellulitis wasn't specifically called MRSA, I wouldn't have redacted it. Essentially, it's one of those, "Well, you're infected with MRSA in one location, why would it be non-resistant elsewhere?" As an example of this line of thinking, an uncomplicated UTI in a sexually active female is E. coli unless it doesn't respond to treatment (cultures aren't even grown if the UTI responds to Bactrim). So, similarly, IF the staph moved elsewhere AND the clinical picture says staph, I'd argue that it's MRSA pending cultures.

On a side note, ladies, if you're sexually active and constantly get UTIs, go pee right after you get done to flush out the little beasties.

[uglyEMT]

Dwayne when I can figure out how to post multiple quotes like you I will answer that way but for now I will just go line for line.

As for him AMA mid treatment. I know MRSA is a nasty bug. I dont think AMA will be enough. If memory serves me correctly, at 36hrs awake doubt it, but MRSA needs aggresive antibiotic cocktails. Cepro I believe is one of them along with some IV solutions and fluids. I cant see a ED ambulating this patient. Not saying he didnt volunterialy walk out but if he left mid treatment it could aggrevate the problem. Thus I am now thinking the bilat noduls could be a manifestation of the skin lesions associated with MRSA

On a side note while commuting home I thought only abut this thread. I came to a conclusion that may or may not be on course but value your input. With the joint pain could we be looking at fibromialgia (sp) or ruhmitoid arthritis? Seems plausible in my opinion.

As for the DVT question is it possible he has a filter in place? I have a frequent flyer that has a chronic history of DVT and has a filter in place, I forget the actual clinical name for it, but its a screen placed in the artery to help stop the clots. Being he has the history add to it the medications, without thinners I may be wrong here, I would think any condition will also have an underlying cardiac or pulminary condition that could be aggrevated.

Thank you for the zebra note. I had it drummed into me during school by the medic instructors not to go looking for zebras. I had more than enough remediation essays because of it, yet it always seemed to prove my point than refute it. So who knows, maybe I have a little House in me after all. And if that causes me to catch something that benifits my patient then I know it cant be a bad thing.

As for my finding to give my report as stated. Bare with me here I may make jumps but hopefully you can see what and where tey came from.

I state it is an infection due to the low grade fever, general malaise, vomiting, diahrea, soreness, MERSA treatment. All point to some sort of infection be it viral or bacterial. Me I would hazard bacterial due to MERSA but wouldnt add that to my report (the bacterial part) Next my cardiopulminary conclusion due to history of DVT, his current medications, and the pale nail beds would lead me to believe profusion is lacking here (I my have missed an SpO2 assesment I appologize for that) thus an underlying condition being aggrevated by the infection.

Thanks for the kudos Dwayne. It makes me feel good hearing an Paramedic liking my way of thinking even though I am a Basic. I know the titles dont really mean much when it comes to knowledge I only state it because I espect your opinion here as well as several others with much more knowledge and experience then me. By letting me know I am hitting the right questions it makes me more confident as a provider that I will ask these questions naturally in my course of the day and maybe just help a patient that much more then simply dropping them off at an ED with a shrug of the shoulders.

As for my screen name you are not the first that said something about it. Maybe this will help shed light. Its an acronym actually (as well as what the ED calls my squad) it stands for Upper Greenwood Lake volly EMT Ok I know I could have done better but just fit me at the time.

Again thanks for the kudos and you keep these coming, push me as a provider, I like the challenge.

[JPINFV]

Thus I am now thinking the bilat noduls could be a manifestation of the skin lesions associated with MRSA

...but the big question regarding the nodules are, "What are the nodules comprised of?" and "Where is the infection?"

As for my screen name you are not the first that said something about it. Maybe this will help shed light. Its an acronym actually (as well as what the ED calls my squad) it stands for Upper Greenwood Lake volly EMT Ok I know I could have done better but just fit me at the time.

Again thanks for the kudos and you keep these coming, push me as a provider, I like the challenge.

There are worse acronyms out there...

[uglyEMT]

...but the big question regarding the nodules are, "What are the nodules comprised of?" and "Where is the infection?"

Hmmm Good question there.

I am wondering, could the infection be in the blood stream?

Hear is a question for the more knowledgeable folks as I dont really know. Could a comprimised circulatory system be the site of a infection? Like, if say the pericardial sac was weakened due to overworking could an infection take root there? And thus get spread through the circulitory system to other areas?

Just a question thats all. You all got me thinking hard about this one. I dont want to google for answers, I want to use my brain to make the leaps from point to point.

[Bieber]

I had a feeling I knew what the diagnosis was after I saw those lesions. I'm very familiar with the disease and I was pleased to find out after I checked the spoiler that I was right.

But I won't be a spoilsport and ruin it before everyone else is done. Great scenario though! Hope to see more like it in the future.

[Just Plain Ruff]

oooh ooooh I know the answer. I know it. But I can't answer it because I read the entire scenario at medscape.

[Happiness]

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.

Ever since Dwyane did this post there have been many things that I have come across in the forums that have been happening in my patients. The reason that I am refering to this senario is because I just had a Pt that had alot of these presentations and Im sure that he had what ever this guy had.

70 yr old Male

Hx of Non Hodkins lymphomia just came out of remission and finished a bought of chemo

Pt is wheel chair bound due to deteriation of t3 and has numbness nipple line down. Pt is able with the aid of a walker to make it to move around the house

Came to hospital with the following symtoms

Low grade fever

generl weakness

BP 140/80

pulse 60

No SOB

Sore red blotches elbows to hands and knees to soles of the feet.

Was medivaced to query endocardioitis

He came home today (look at my status)a very happy man.

His treatment is pregnazone.................and is very rare, Dr's may see it once a year

Try to take stabs at what this gentleman has as above is all the info that I can give you.

I will give you the answer and I will post what I can find on Google in a few days

[Aussieaid]

Ok, I am going to bite and have managed to have enough willpower to resist Googling or reading the Medscape article so bear with me! I used to receive Medscape's x-ray presentations but for some reason no longer do. Good incentive to sign back up and also get these presentations as well.

I was also leaning towards an autoimmune disease or an exotic viral or parasitic infection but you seemed to be under the impression that he might be more of a homebody or "non-traveling type person". I am not 100% sure if Lupus is an autoimmune disease but it does fit this picture. The elevated ESR is usually a sign of inflammation and is often elevated in arthritis and sepsis. The history of intermittent fever, weakness, malaise, weight loss, joint swelling and nausea can all be symptoms of Lupus. I think with Lupus it rarely presents with the exact same symptoms in any 2 people which can make it a challenge to diagnose sometimes.

I am also looking at the anemia and the high end of normal BUN and Creatinine along with slightly elevated BP as signs of early kidney involvement. Elevated BP could also be attributed to the swollen and painful joints. I have taken care of a number of children in the PICU with kidney failure from Lupus.

I don't recall if Lupus has specific "triggers" but he has a pretty complex medical history and multiple possible triggers for an autoimmune disease.

The pale nail beds could be a sign of anemia but they could also be mild Reynaud's Phenomenon which can be associated with Lupus.

Any chance he had a "butterfly" rash on his face?

Now that I have contributed my 2 cents (Cheat free!!! ) I am off to find the article and see how far off base I am!

Thanks for the brain exercise, Dwayne.

Edited December 19, 2010 by Aussieaid