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Old 12-04-2013, 14:39   #46
Santo Tomas
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Originally Posted by x SF med View Post
Thomas, you will kindly STFU, and not get friggin snarky with our fellow QP/18D turning doctor... an apology for the tone and tenor of your post is not expected, but demanded. Ender is a fully qualified 18D and is currently in Med School, we have a couple of PAs and couple of Doctors and a few 18Ds stretching their minds on this, it's not about you.

...and for your edification, this is Medical English, with a little Latin (a medical convention) thrown in - basic medical terminology.

We do not perform internet diagnosis on PS, go see your doctor and get the traditional work ups done by a certified physician on your own dime... this is a training and gut check scenario for the medically inclined on the board.

If an apology is not forthcoming, a moderator will take over.
I PM'd Ender
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Old 12-04-2013, 14:52   #47
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Originally Posted by PedOncoDoc View Post
Acute leukemia and mutliple myeloma may also present in a similar fashion.
Quite true

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Old 12-04-2013, 16:22   #48
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Originally Posted by ender18d View Post
Problem list:
Vertebral Pain
Fever
Night Sweats
Pallor
Recent Dental Work


Give me your differentials!
1. Osteomyelitis - one should also evaluate for endocarditis given recent dental work - does he have a murmur, any splinter hemorrhages until his fingernails?

2. New onset acute leukemia (also should consider lymphoblastic lymphoma or other malignancy).

3. Vertebral fracture and concomitant (and unrelated) random infection.
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Old 12-04-2013, 17:11   #49
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Has anyone done a thorough physical exam? Was he shot and didn't know it? Did a camel spider make him a host nation to its young?

Come on people......
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Old 12-04-2013, 17:20   #50
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Ender,
GREAT scenario.
Nice to have someone else throw in one of these for a change.

Couple of questions I have that I don't recall seeing asked/answered ....

1) What country are you, is this pt. in?
2) Pt. states that father had Hx of Lower back pain. Was there any diagnosis on what caused his dad's back pain.
3) Can you in anyway, or is there any way to preform a spinal tap?
4) Does he c/o of a headache, head tilt to chin pain, bright lights bother him? (Going down the r/o Spinal Meningitis route here.)

I've noticed that you've brought up quite repeatedly about the pt. having dental work done. Where was this work done at? In a regular DDS's office or some other place. I ask because if done in a regular DDS office, I know those chairs they use do NOT supply or support the Lumbar area. So this could have exasperated an underlying condition.

5) What procedure was done in the DDS office? Was he put under with anesthetic for a surgical procedure or was it just a regular cleaning of his choppers?

I think he might have some sort of bacterial infection caused by the procedure done by the Jawbreaker. Will explore a little more after above Q's are answered.
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Last edited by Sdiver; 12-04-2013 at 19:04.
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Old 12-04-2013, 17:35   #51
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With back pain, fever and night sweats Potts Disease is also in the differential.
Potts Disease is osteomyelitis of the spine caused by mycobacterium tuberculosis (TB) usually acquired from drinking unpasteurized milk in third world countries.
I've seen one case in an active duty soldier.
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Old 12-04-2013, 18:04   #52
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Originally Posted by doctom54 View Post
With back pain, fever and night sweats Potts Disease is also in the differential.
Potts Disease is osteomyelitis of the spine caused by mycobacterium tuberculosis (TB) usually acquired from drinking unpasteurized milk in third world countries.
I've seen one case in an active duty soldier.
That is a very good DDx point. The night sweats initially had me thinking about TB, but it just didn't fit the recent history. Talkin about Zebra's That fits especially with the immature neutrophils and neutrophilia (leukocytosis with left shift). I guess sometimes the hoof beats are from Zebras.

So has Team Sergeant been drinking unpasteurized milk? Otherwise, I'm thinking the proximate cause for the osteomyelitis is the recent dental work.

Still holding with my original plan to ship TS out on the next thing smokin'. All of the likely possibilities are well outside my ability to adequately treat him in the field.
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Old 12-04-2013, 18:08   #53
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Kidney stone. Tell 'im to drink a 2-qt canteen full o' water, move out and draw fire.
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Old 12-04-2013, 20:51   #54
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Amateur here...do let me know if I should stand down...

Has the pt had Chickpox as a child?
Has the pt been under greater than usual stress this past 1-2 months, prior to deploy?

S
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Old 12-04-2013, 21:23   #55
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Quote:
Also, palpation of a varicella zoster outbreak site normally causes a more regional than point pain.
Yeah I was thinking the same thing, the pain description is a little out of wack for Shingles.

Quote:
Good thinking, but already covered with visual exam question - no blisters/ rash of shingles.
However, pain and fever / "out of sorts" can on occasion appear up to a few days before visual blistering.

It was a long shot, the only reason I even brought it up is lisinopril has been known to increase chance of herpes zoster.

Another question...how long has pt been on meds, the sweats / out of sorts can be the meds, taking these symptoms out of the mix.

Also, any meds during dental work?

S
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Last edited by Scimitar; 12-04-2013 at 21:58.
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Old 12-04-2013, 22:11   #56
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Quote:
Originally Posted by Brush Okie View Post
Question on Hx.

Any Nausea and vomiting?
No.

Quote:
Originally Posted by Brush Okie View Post
Does the pain get worse after meals especially fatty meals?
No

Quote:
Originally Posted by Brush Okie View Post
Any abd pain or tenderness?
Abdomen appears unremarkable, is soft and supple in 4 fields w/ no guarding or rigidity. Bowel sounds auscultated.

Quote:
Originally Posted by Brush Okie View Post
Does he have a fever?
See vitals.

Quote:
Originally Posted by Brush Okie View Post
What is the malaria possibility in the region or has he been in a malaria region recently?
The patient is in a region with chloroquine resistant malaria, and is on prophylaxis as noted. The patient claims good compliance.

Quote:
Originally Posted by Brush Okie View Post
Any stiff neck or Sx of flu other than feels like shit and night sweats?
No nuchal rigidity noted. Negative NVD, cough, rhinorrhea, sore throat, etc.

Quote:
Originally Posted by Sdiver View Post
1) What country are you, is this pt. in?
2) Pt. states that father had Hx of Lower back pain. Was there any diagnosis on what caused his dad's back pain.
3) Can you in anyway, or is there any way to preform a spinal tap?
4) Does he c/o of a headache, head tilt to chin pain, bright lights bother him? (Going down the r/o Spinal Meningitis route here.)
1. Lets say sub-saharan Africa somewhere. I'm not picky for this scenario. Someplace hot that has malaria and a bunch of other bad things. Pick a country.
2. His dad was always complaining about his bad back that he got jumping into Market Garden, but no diagnosis that patient can recall.
3. Could you? Would you? (assuming you have the equipment to do the procedure)
4. Negative nuchal rigidity, photophobia.

Quote:
Originally Posted by Sdiver View Post
I've noticed that you've brought up quite repeatedly about the pt. having dental work done. Where was this work done at? In a regular DDS's office or some other place. I ask because if done in a regular DDS office, I know those chairs they use do NOT supply or support the Lumbar area. So this could have exasperated an underlying condition.
Work was done at a military dental facility.

Quote:
Originally Posted by Sdiver View Post
5) What procedure was done in the DDS office? Was he put under with anesthetic for a surgical procedure or was it just a regular cleaning of his choppers?
He says his mouth was a real cesspool according to the dentist, but he has trouble remembering any particular words. When you say "root abscess," he seems to think that rings a bell. Local anesthetic was used.

Quote:
Originally Posted by Trapper John View Post
So has Team Sergeant been drinking unpasteurized milk? Otherwise, I'm thinking the proximate cause for the osteomyelitis is the recent dental work.
Negative

Quote:
Originally Posted by Scimitar View Post
Amateur here...do let me know if I should stand down...

Has the pt had Chickpox as a child?
Has the pt been under greater than usual stress this past 1-2 months, prior to deploy?

S
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Quote:
Originally Posted by Scimitar View Post

Another question...how long has pt been on meds, the sweats / out of sorts can be the meds, taking these symptoms out of the mix.
PT has been taking lisinopril since his mid 30's. He started the malaria prophylaxis a few days prior to deployment.

Quote:
Originally Posted by Scimitar View Post
Also, any meds during dental work?

S
The patient does not know if the dentist used any meds other than anesthetic... he just remembers a bunch of needles. He was given a prescription for something by the dentist, but he didn't feel sick so he ignored it.
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Last edited by ender18d; 12-04-2013 at 22:14.
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Old 12-04-2013, 22:15   #57
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Originally Posted by ender18d View Post
The patient does not know if the dentist used any meds other than anesthetic... he just remembers a bunch of needles. He was given a prescription for something by the dentist, but he didn't feel sick so he ignored it.
Now we're getting somewhere! (Sorry, couldn't resist; even a former Bravo knows how much sympathy to expect when you tell the medic you FTFSI.)
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Old 12-04-2013, 22:39   #58
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Two quick questions ...

1) how long has he been taking his Lisinopril, and most importantly the Atovaquone/Proguanil ?

2) What is his race/ethnicity ?


ETA some differential Dx's .....

Dad's back pain came from jump into Holland so we can r/o that being a genetic trait.

Mom's RA is a possible genetic trait. Which in combination with the Lisinopril could exacerbate the back pain which is a possible side effect of Lisinopril.

The back pain can also be a hypersensitivity to the Malarone (would really like to know his race/ethnicity .... I reference the M*A*S*H episode with Klinger and Goldman taking the Primaquine.) Also Black's having an acute hypersensitivity to Malaria drugs.

Also, the combination of the Mararone and the supplements he's taking may be causing an adverse reaction. The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly.

Also possible, a combination of all three above.
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Old 12-04-2013, 22:45   #59
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An echo of his heart would be nice. Can we get a EKG to compare against a baseline?

Lab work - Lites/UA w diff (specifically creatinine level)?

How much ibuprofen/naproxen has he been taking?
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Old 12-05-2013, 05:24   #60
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Somewhere along the line I missed answering:
Cardiac exam demonstrates RRR, S1/S2 w/o murmurs, gallops, or rubs. PMI @ 5th ICS MCL. No splinter hemorrhages either, but great thinking on all of the above.

Quote:
Originally Posted by Peregrino View Post
Now we're getting somewhere! (Sorry, couldn't resist; even a former Bravo knows how much sympathy to expect when you tell the medic you FTFSI.)
Indeed!

Quote:
Originally Posted by Brush Okie View Post
What is he taking the lisinopril for? High BP or kidney problems?

I looked it up and found it can cause hyperkalemia. Sooo I am looking at possibly kidney issue ie kidney problems and or hyperkalemia. Any pedal edema? DC the lisinopril. He did have some darker urine correct? Possable systemic infection due to not following through with dental med working with BP med?
PT has previously noted history of HTN.

No peripheral edema noted on exam.

The urine was described as mid-yellow with no heme on dipstick and I will add no proteinurea either.

Quote:
Originally Posted by Sdiver View Post
Two quick questions ...

1) how long has he been taking his Lisinopril, and most importantly the Atovaquone/Proguanil ?

2) What is his race/ethnicity ?


ETA some differential Dx's .....

Dad's back pain came from jump into Holland so we can r/o that being a genetic trait.

Mom's RA is a possible genetic trait. Which in combination with the Lisinopril could exacerbate the back pain which is a possible side effect of Lisinopril.

The back pain can also be a hypersensitivity to the Malarone (would really like to know his race/ethnicity .... I reference the M*A*S*H episode with Klinger and Goldman taking the Primaquine.) Also Black's having an acute hypersensitivity to Malaria drugs.

Also, the combination of the Mararone and the supplements he's taking may be causing an adverse reaction. The effects of some drugs can change if you take other drugs or herbal products at the same time. This can increase your risk for serious side effects or may cause your medications not to work correctly.

Also possible, a combination of all three above.
Medication dates already noted a few posts ago.

He's Caucasian.

Quote:
Originally Posted by MR2 View Post
An echo of his heart would be nice. Can we get a EKG to compare against a baseline?

Lab work - Lites/UA w diff (specifically creatinine level)?

How much ibuprofen/naproxen has he been taking?

You already have the diff... I think chemistries stretch what one might reasonably be expected to have given the scenario.

He has not yet taken any NSAIDs.
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