y***d
发帖数: 33 | 1 Looks like people enjoyed last week's case. Here's the second one. This one
is shorter and more straightforward.
CC: fever, abdominal pain and arthralgias
HPI: 31 yo merchant ship worker p/w 3 days of acute febrile illness. 16 days
PTA, he flew from India to Long beach, where he had a negative pre-ship
exam including labs. Then patient boarded an oil tanker and sailed up west
coast. 3 days PTA, he developed mild mid-epigastric and LUQ pain. Over the
first day, pain worsened and was associated with shaking chills and fever.
He then developed a severe headache and marked arthralgias. Over the three
days, he was progressive worse. He was treated with Tylenol and 2 doses of
unknown antibiotics by the ship doctor without improvement. He was then sent
to ER for evaluation.
ROS: No nausea/vomiting/diarrhea. No sick contact.
PMH: No h/o hepatitis, STDs or blood disorders.
Meds: Tylenol, unknown antibiotics
SH: Lives in India with wife and 14 month older daughter. Both wife and the
daughter are healthy. No tob/ETOH/drugs. Monogmous with wife,no high risk
behaviors. Worked as an engineer on the oil tanker.
FH: none.
Question:
This is a case of fever in traveler. List your ddx and any additional
history elements you would want to know. I will answer the ones I can
tomorrow. |
A*******s
发帖数: 9638 | |
a*********1
发帖数: 872 | 3 thyphoid fever?
blood culture, stool culture |
a*********1
发帖数: 872 | 4 dengue fever?
antibody for dengue virus
any swollen lymph node? |
A*******s
发帖数: 9638 | 5 Besides Dengue，bacteria such as Salmonella, Shigella, Yersinia or
Campylobacter, may also cause dysentery and reactive arthritis.
Some STDs should be considered as well.
【在 a*********1 的大作中提到】
: dengue fever?
: antibody for dengue virus
: any swollen lymph node?
|
c*******s
发帖数: 399 | 6 dd: Bacterimia VS meningitis?
viral
bacterial
Parasite: (Malaria?)
peripheral blood smear
LP ( any stiff neck)
LFT
CBC, BMP
blood culture
UA
Stool culture, wbc ect
one
days
three
【在 y***d 的大作中提到】
: Looks like people enjoyed last week's case. Here's the second one. This one
: is shorter and more straightforward.
: CC: fever, abdominal pain and arthralgias
: HPI: 31 yo merchant ship worker p/w 3 days of acute febrile illness. 16 days
: PTA, he flew from India to Long beach, where he had a negative pre-ship
: exam including labs. Then patient boarded an oil tanker and sailed up west
: coast. 3 days PTA, he developed mild mid-epigastric and LUQ pain. Over the
: first day, pain worsened and was associated with shaking chills and fever.
: He then developed a severe headache and marked arthralgias. Over the three
: days, he was progressive worse. He was treated with Tylenol and 2 doses of
|
c*******s
发帖数: 399 | 7 dd: Bacterimia VS meningitis?
viral
bacterial
Parasite: (Malaria? Ameoba? )
peripheral blood smear
LP ( any stiff neck)
LFT
CBC, BMP
blood culture
UA
Stool culture, wbc ect. 0and p
one
days
three
【在 y***d 的大作中提到】
: Looks like people enjoyed last week's case. Here's the second one. This one
: is shorter and more straightforward.
: CC: fever, abdominal pain and arthralgias
: HPI: 31 yo merchant ship worker p/w 3 days of acute febrile illness. 16 days
: PTA, he flew from India to Long beach, where he had a negative pre-ship
: exam including labs. Then patient boarded an oil tanker and sailed up west
: coast. 3 days PTA, he developed mild mid-epigastric and LUQ pain. Over the
: first day, pain worsened and was associated with shaking chills and fever.
: He then developed a severe headache and marked arthralgias. Over the three
: days, he was progressive worse. He was treated with Tylenol and 2 doses of
|
y***d
发帖数: 33 | 8 Patient didn't report a rash but there was one on exam. No stiff neck.
Exam:
T 39.3 P 104 BP 111/55 RR 18 O2sat 98%RA
Gen – mild discomfort, vary faint macular rash on abdomen, no petichae
HEENT – bilateral conjunctival injection, EOMI, no proptosis. No sinus
tenderness. OP clear. Neck soft, supple, no LAD.
CV – tachy, regular, 2/6 systolic mumur at LSB (flow murmur)
Resp – CTAB, no w/c/r
Abd – soft, obese, ND, mild epigastric and LUQ TTP, negative Murphy's sign,
HSM not felt
Ext – no e/c/c, joints normal w/o effusion
Neuro – grossly non-focal |
c*******s
发帖数: 399 | 9 lyme disease
sign,
【在 y***d 的大作中提到】
: Patient didn't report a rash but there was one on exam. No stiff neck.
: Exam:
: T 39.3 P 104 BP 111/55 RR 18 O2sat 98%RA
: Gen – mild discomfort, vary faint macular rash on abdomen, no petichae
: HEENT – bilateral conjunctival injection, EOMI, no proptosis. No sinus
: tenderness. OP clear. Neck soft, supple, no LAD.
: CV – tachy, regular, 2/6 systolic mumur at LSB (flow murmur)
: Resp – CTAB, no w/c/r
: Abd – soft, obese, ND, mild epigastric and LUQ TTP, negative Murphy's sign,
: HSM not felt
|
A*******s
发帖数: 9638 | 10 This exam is almost normal except a fever. Why Lyme?
【在 c*******s 的大作中提到】
: lyme disease
:
: sign,
|
|
|
V*****G
发帖数: 337 | 11 Nice. Louzhu is saying this is a straightforward case, I don't feel that way....
【在 A*******s 的大作中提到】
: Any rashes?
|
V*****G
发帖数: 337 | 12 Nice, both of your differential are hard to come up with. LouZhu is playing
tough ball, don't mention rash at all in Hx. I will add rickettsial
diseases:
Endemic typhus (fleas)––R. typhi. centrally and spreads out:
Epidemic typhus (human body louse)––R. prowazekii. Typhus rash starts on
the Trunk.”
Ehrlichiosis (tick)––Ehrlichia.
Q fever (inhaled aerosols)––Coxiella burnetii.
Malaria needs to be ruled out too (copyright of chestnut, although I thought about this too).
Workup and management:
CBC, peripheral smear, blood culture,
Weil-felix reaction; Typhus-antibody
Antibody to salmonella typhus in blood and urine (copyright of aquafina)
Antibody titer for dengue virus types (copyright of aquafina)
CMP, BUN Cr LFT
UA,
Stool analysis and culture
U/S abd
I will start pt on tetracylcine now.
【在 a*********1 的大作中提到】
: thyphoid fever?
: blood culture, stool culture
|
V*****G
发帖数: 337 | 13 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002350/
Dengue fever
Dengue fever is a virus-based disease spread by mosquitoes.
auses, incidence, and risk factors
Dengue fever is caused by one of four different but related viruses. It is
spread by the bite of mosquitoes, most commonly the mosquito Aedes aegypti,
which is found in tropic and subtropic regions. This includes parts of:
Indonesian archipelago into northeastern Australia
South and Central America
Southeast Asia
Sub-Saharan Africa
Dengue fever is being seen more in world travelers.
Dengue fever should not be confused with Dengue hemorrhagic fever, which is
a separate disease that is caused by the same type of virus but has much
more severe symptoms.
Symptoms
Dengue fever begins with a sudden high fever, often as high as 104 - 105
degrees Fahrenheit.
A flat, red rash may appear over most of the body 2 - 5 days after the fever
starts. A second rash, which looks like the measles, appears later in the
disease. Infected people may have increased skin sensitivity and are very
uncomfortable.
Other symptoms include:
Headache (especially behind the eyes)
Fatigue
Joint aches
Muscle aches
Nausea
Swollen lymph nodes
Vomiting
Signs and tests
Tests that may be done to diagnose this condition include:
Antibody titer for dengue virus types
Complete blood count (CBC)
Serology studies to look for antibodies to dengue viruses
Treatment
There is no specific treatment for dengue fever. You will need fluids if
there are signs of dehydration. Acetaminophen (Tylenol) is used to treat a
high fever. Avoid taking aspirin.
【在 a*********1 的大作中提到】
: dengue fever?
: antibody for dengue virus
: any swollen lymph node?
|
A*******s
发帖数: 9638 | 14 victor, 你有反客为主之嫌， 哈哈。
,
【在 V*****G 的大作中提到】
: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002350/
: Dengue fever
: Dengue fever is a virus-based disease spread by mosquitoes.
: auses, incidence, and risk factors
: Dengue fever is caused by one of four different but related viruses. It is
: spread by the bite of mosquitoes, most commonly the mosquito Aedes aegypti,
: which is found in tropic and subtropic regions. This includes parts of:
: Indonesian archipelago into northeastern Australia
: South and Central America
: Southeast Asia
|
a*********1
发帖数: 872 | 15 每次看到你的分析贴，都忍不住要给你发包子.....
playing
thought about this too).
【在 V*****G 的大作中提到】
: Nice, both of your differential are hard to come up with. LouZhu is playing
: tough ball, don't mention rash at all in Hx. I will add rickettsial
: diseases:
: Endemic typhus (fleas)––R. typhi. centrally and spreads out:
: Epidemic typhus (human body louse)––R. prowazekii. Typhus rash starts on
: the Trunk.”
: Ehrlichiosis (tick)––Ehrlichia.
: Q fever (inhaled aerosols)––Coxiella burnetii.
: Malaria needs to be ruled out too (copyright of chestnut, although I thought about this too).
: Workup and management:
|
A*******s
发帖数: 9638 | 16 支持， 版副你就放手发， 把金库发光后我们可以再挣。
【在 a*********1 的大作中提到】
: 每次看到你的分析贴，都忍不住要给你发包子.....
:
: playing
: thought about this too).
|
V*****G
发帖数: 337 | 17 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
A*******s
发帖数: 9638 | 18 I googled too and found there was no rash mentioned in the history to match
Dengue. LOL.
.
【在 V*****G 的大作中提到】
: I don't have much knowledge about this disease, so I searched, found
: surprisingly matching presentation. Then posted here for people like me.
: My purpose is to show aquafina is superb to come up with this differential.
: Nice.
|
V*****G
发帖数: 337 | 19 Even you can think of Dengue, that is already very good.
Niu!
match
【在 A*******s 的大作中提到】
: I googled too and found there was no rash mentioned in the history to match
: Dengue. LOL.
:
: .
|
V*****G
发帖数: 337 | 20 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
|
|
V*****G
发帖数: 337 | 21 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
V*****G
发帖数: 337 | 22 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
V*****G
发帖数: 337 | 23 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
V*****G
发帖数: 337 | 24 Sorry guys. My phone got drunken and posted messages by itself.
.
【在 V*****G 的大作中提到】
: I don't have much knowledge about this disease, so I searched, found
: surprisingly matching presentation. Then posted here for people like me.
: My purpose is to show aquafina is superb to come up with this differential.
: Nice.
|
V*****G
发帖数: 337 | 25 I don't have much knowledge about this disease, so I searched, found
surprisingly matching presentation. Then posted here for people like me.
My purpose is to show aquafina is superb to come up with this differential.
Nice.
【在 A*******s 的大作中提到】
: victor, 你有反客为主之嫌， 哈哈。
:
: ,
|
A*******s
发帖数: 9638 | 26 Just keep it going, and going and going....
【在 V*****G 的大作中提到】
: Sorry guys. My phone got drunken and posted messages by itself.
:
: .
|
V*****G
发帖数: 337 | 27 I cannot believe it is still doing it, my gosh. I really need to figure out
what is going on with this drunken phone.
【在 A*******s 的大作中提到】
: Just keep it going, and going and going....
|
A*******s
发帖数: 9638 | 28 I think it is the battery's fault. I bet it is an Energizer battery: It
just keep it going and going and going.... lol
Remember the ads?
out
【在 V*****G 的大作中提到】
: I cannot believe it is still doing it, my gosh. I really need to figure out
: what is going on with this drunken phone.
|
a*********1
发帖数: 872 | 29 一遍又一遍的说superb，俺真是受宠若惊 lol
.
【在 V*****G 的大作中提到】
: I don't have much knowledge about this disease, so I searched, found
: surprisingly matching presentation. Then posted here for people like me.
: My purpose is to show aquafina is superb to come up with this differential.
: Nice.
|
s****p
发帖数: 1087 | 30 A very nice post. Thanks for input.
one
days
three
【在 y***d 的大作中提到】
: Looks like people enjoyed last week's case. Here's the second one. This one
: is shorter and more straightforward.
: CC: fever, abdominal pain and arthralgias
: HPI: 31 yo merchant ship worker p/w 3 days of acute febrile illness. 16 days
: PTA, he flew from India to Long beach, where he had a negative pre-ship
: exam including labs. Then patient boarded an oil tanker and sailed up west
: coast. 3 days PTA, he developed mild mid-epigastric and LUQ pain. Over the
: first day, pain worsened and was associated with shaking chills and fever.
: He then developed a severe headache and marked arthralgias. Over the three
: days, he was progressive worse. He was treated with Tylenol and 2 doses of
|
|
|
y***d
发帖数: 33 | 31 Sorry for the absence yesterday. Lost my labtop to burglary. What a pain!
Anyway, looks like VictorG kept everyone entertained at least.
So I believe we left off at labs. Since this is a relative short case, I
will post the initial labs along with the hospital course today. Final
diagnosis tomorrow.
Na 135 TB 1.0 WBC 2.8 PT 16.2
K 4.4 AST 55 Hgb 15.2 PTT 30.6
Cl 103 ALT 105 Hct 43.8 INR 1.3
HCO3 24 ALP 119 PLT 55
BUN 16 TP 7.8 Poly 69
Cr 1.5 Alb 3.8 Lymph 18 Lactate 1.7
Glc 101 Mono 12
Ca 8.3 Lipase 65 MCV 86
Bcx pending
CT abd: hepatosplenomegaly. Localized mid jejunal dysmotility w/o frank
obstruction. Gall bladder and pancreas unremarkable. No appendicitis.
These are the initial data available to the admitting team. The admitting
team ordered some more work-up. Patient got one dose of Zosyn by the ER and
no further antibiotics. He was hydrated with fluids while the team was
waiting for more results to come back. His fever, leukpenia,
thrombocytopenia and renal failure resolved over 2-3 days, and he was
discharged before the test result that confirmed his diagnosis came back.
So, what is your diagnosis and what test would you order? |
A*******s
发帖数: 9638 | 32 what is your diagnosis?
Dengue fever.
what test would you order?
anti-Dengue AB. |
y***d
发帖数: 33 | 33 It is Dengue! Both Dengue IgG and IgM came back positive after patient was
discharged. Of course you would also want thin and thick blood smear to r/o
malaria since the presentation can be very similar.
Reason this case was interesting to me is that the patient's symptom
basically started on day 14. Classic teaching has been if the fever starts
14 days after the patient has left the endemic area then Dengue can be
excluded. He was right on the cut off. |
s****p
发帖数: 1087 | 34 我很好奇，看病和什么职业用的思维比较相像？
侦探？
o
【在 y***d 的大作中提到】
: It is Dengue! Both Dengue IgG and IgM came back positive after patient was
: discharged. Of course you would also want thin and thick blood smear to r/o
: malaria since the presentation can be very similar.
: Reason this case was interesting to me is that the patient's symptom
: basically started on day 14. Classic teaching has been if the fever starts
: 14 days after the patient has left the endemic area then Dengue can be
: excluded. He was right on the cut off.
|
A*******s
发帖数: 9638 | 35 Thanks for this interesting case. I have learned again. Is Dengue now the
most common disease among the travellers coming to U.S?
o
【在 y***d 的大作中提到】
: It is Dengue! Both Dengue IgG and IgM came back positive after patient was
: discharged. Of course you would also want thin and thick blood smear to r/o
: malaria since the presentation can be very similar.
: Reason this case was interesting to me is that the patient's symptom
: basically started on day 14. Classic teaching has been if the fever starts
: 14 days after the patient has left the endemic area then Dengue can be
: excluded. He was right on the cut off.
|
A*******s
发帖数: 9638 | 36 Medicine= Science + art.
Detector= life experience + drama.
【在 s****p 的大作中提到】
: 我很好奇，看病和什么职业用的思维比较相像？
: 侦探？
:
: o
:
|
d**o
发帖数: 618 | 37 Also, the patient's fever history may not be reliable. He could have fever
long before he realized it.
Great case, thanks a lot for the detailed presentation!
【在 y***d 的大作中提到】
: It is Dengue! Both Dengue IgG and IgM came back positive after patient was
: discharged. Of course you would also want thin and thick blood smear to r/o
: malaria since the presentation can be very similar.
: Reason this case was interesting to me is that the patient's symptom
: basically started on day 14. Classic teaching has been if the fever starts
: 14 days after the patient has left the endemic area then Dengue can be
: excluded. He was right on the cut off.
|
N*G
发帖数: 217 | |
V*****G
发帖数: 337 | 39 You are right. I took the battery out, looks like that works......
【在 A*******s 的大作中提到】
: I think it is the battery's fault. I bet it is an Energizer battery: It
: just keep it going and going and going.... lol
: Remember the ads?
:
: out
|
V*****G
发帖数: 337 | 40 Nice case.
Can you talk more about diagnosis process of the team (attendings, pgys etc)
? As Dengue fever is a common disease here, right?
o
【在 y***d 的大作中提到】
: It is Dengue! Both Dengue IgG and IgM came back positive after patient was
: discharged. Of course you would also want thin and thick blood smear to r/o
: malaria since the presentation can be very similar.
: Reason this case was interesting to me is that the patient's symptom
: basically started on day 14. Classic teaching has been if the fever starts
: 14 days after the patient has left the endemic area then Dengue can be
: excluded. He was right on the cut off.
|
