Before you can do anything the ER nurses are on him like vampires, drawing all sorts of labs, lavender, speckled red, purple, green top, and extra plain red tops just in case, a set of blood cultures, and ask him to pee mid-stream in a cup, and attach 12 leads for an ekg.
The patient seems slightly more alert now that he is lying flat/supine, and in this position his bp improves slightly to 88/50. IV NS is still going in wide-open.
You procede to make him undress to look over his body as you recall the FP saying something about changes in his skin. You also begin to take a slightly more detailed history. Since in your mind (collective) there is some doubt about giving hydrocortisone, you hold off thinking you can do a quick history and physical before giving him any meds while continuing to monitor his vitals. As you procede to quickly remove the man's clothing you notice a generalized increases in pigmentation over the extensor surfaces of the knees, the face, the knuckles of both hands, in the skin creases of the palmar surfaces of his hands and in an old well healed scar on the patient's right calf. The skin does not look like generalized bronze skin, but instead has discrete areas of darkening (natural pigment, not ecchymosis or petichae, or rash like).
Further questioning reveals: He is in the end stages of getting over a uri and still has some nasal congestion. He started to feel really lousy about 4 days ago with the onset of URI type symptoms fever, running nose, etc (no (productive) cough).
The weight loss occurred over the past 2-3 weeks and he was not intentionally trying to loose weight.
No night sweats, no chilles, no lumps or bumps, although he did have a low grade fever about 4 days ago at the beginning of his uri. The generalized weakness/fatigue/ lightheadedness/dizzinesss (head falling to the ground) has gotten worse over the past two weeks especially since the onset of the URI.
No recent travel outside of the USA, he lives and works as a computer technition in philadelphia. No recent sick contacts, except his office workers who came down with same URI symptoms 2 days prior to him. He has not been sexually active for the past 6 months and only has sex with women with condoms (always).
His po intake has been average and denies nausea or vomiting or diarrhea. Although he says he has been feeling more depressed lately, and that this is unusual for him as he is usually a happy go lucky guy.
No change in his bowel or bladder habits.
The patient's vitals continue to be unchanged from lying supine. You start to do a quick physical noting to yourself that you can always ask more questions at a later time.
Gen: A/0 x3 NAD
HEENT: EOMI, PERRLA, NC/AT Multilpe increased areas of mucous membraine
pigmentation with some areas of much darker pigmentation in the mouth. Neck supple, no JVD, no palpable lympadenopathy. No neck stiffness.
CV: RRR (although borderline tachy) s1 s2 no m/r/g.
Lungs: Clear B/L
Abd: + NA Bowel sounds, soft, nt nd, no hepatosplenomegaly, no gaurding, no rebound.
Ext: No clubbing cynanosis or edema no chord, no homann's.
Neuro: Non-focal. CN 2-12 grossly intact, motor strength5/5 x 4, sensation grossly intact/symmetric, 2+ x4 DTR. unable to asses gait.
Derm: Multiple increased areas of pigmentation along the face, the extensor surfaces of the knees, the creases in the palmar surface of the hand and in an old scar in R calf. No petichae, no echymosis or other macular/papular rashes.
(Next time I will just give you the pertinent positives/negs).
You start to notice that nurses have connected the man to the EKG machine. You let them do their business. You look at it. NSR 98 BPM, normal axis, no acute ST changes, slightly high T waves.
The nurses also do a random finger stick: 60.
Labs are still cooking. Portable CXR man is here, everyone clears out as he yells XRAY and ducks behind a table holding the xray button in his hand.
What do you do now?
