Elementary Diagnosis & Treatment

[Dr Bartlet]

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22 year old patient presents with pain throughout her body especially her joints. She has slight swelling around her fingers and toes and pain in her side that's worse when she breathes. She has a rash on her chest and arms that gets worse with sun exposure. Labs come back normal except positive ANA 1:320 and positive protein in urine 2+.

What say you?

 

[HMSBeagle]

Sle.

 

[vtucci]

Elementary indeed. I am waiting for the punchline.

 

[Dr Bartlet]

This stumped a third year last week.

 

[dbhvt]

doh
HMSBeagle beat me to it.
you sneak in three little letters and a period, and of course i'm not going to see it.

 

[HMSBeagle]

doh
HMSBeagle beat me to it.
you sneak in three little letters and a period, and of course i'm not going to see it.

 

[Scaredshizzles]

Well in fairness to the 3rd year, real life SLE is harder to diagnose than most of those vignettes....it is hard to differentiate vague autoimmune symptoms in a woman from the propensity some women have to somatasize their stress and depression by making countless minor complaints about their health.

 

[Blade28]

Well in fairness to the 3rd year, real life SLE is harder to diagnose than most of those vignettes....it is hard to differentiate vague autoimmune symptoms in a woman from the propensity some women have to somatasize their stress and depression by making countless minor complaints about their health.

So true!

 

[MattD]

yup, vignettes have nice keywords..

lemme make it even better 🙂

22 yo female with arthralgia, digital swelling, proteinuria, positive ANA, and a photosensitive rash in a malar distribution.


It's like I'm reading robbins! 🙂

 

[vtucci]

Well in fairness to the 3rd year, real life SLE is harder to diagnose than most of those vignettes....it is hard to differentiate vague autoimmune symptoms in a woman from the propensity some women have to somatasize their stress and depression by making countless minor complaints about their health.

Once the ANA titer is back though in view of the hx and sx, game over.

 

[MattD]

Once the ANA titer is back though in view of the hx and sx, game over.

if you ordered it...

 

[roja]

Just to make it fun... remember, ANA and rheumatoid factors are very nonspecific tests. they mean little outside of the right clinical picture

 

[Hard24Get]

Just to make it fun... remember, ANA and rheumatoid factors are very nonspecific tests. they mean little outside of the right clinical picture

It totally sucks when some goober orders one (or both) of them without any real indication, and then they come back positive or borderline positive... just complicates everything.

yeah, most of those rheumatologic diseases sound so vague, you literally have to make your problem list and use Occam's razor to resolve it. Even attendings can have days on the medicine floor before the eureka moment. 🙂

 

[vtucci]

if you ordered it...

Based on the OP's story, they did order it and the dx was still missed by the student.

It would be really bad to miss ordering an ANA with the clinical picture provided, the rash, swelling of fingers/toes. There was nothing in the history provided to suspect a reaction from a tetracycline or other med but that could be a consideration.

 

[MattD]

Based on the OP's story, they did order it and the dx was still missed by the student.

It would be really bad to miss ordering an ANA with the clinical picture provided, the rash, swelling of fingers/toes. There was nothing in the history provided to suspect a reaction from a tetracycline or other med but that could be a consideration.

Oh sure, I was just being all general-like. Wasn't talking about the actual case anymore. But that raises a good point, because it doesn't make any sense for the team to have ordered the ANA unless SLE (or SOME sort of AI disorder) was on their differential, and when it came back positive................

Lesson learned: Don't order tests if you're going to ignore the results 🙂

 

[roja]

It totally sucks when some goober orders one (or both) of them without any real indication, and then they come back positive or borderline positive... just complicates everything.

yeah, most of those rheumatologic diseases sound so vague, you literally have to make your problem list and use Occam's razor to resolve it. Even attendings can have days on the medicine floor before the eureka moment. 🙂

yes, 2 years in a peds rheum clinic, plus thinking I would do peds rheum until the end of my 3rd year and the misuse and representation of rheumatological diseases drives me batty.

But I did manage to finally diagnose one the other day in the ED.

 

[RxnMan]

It totally sucks when some goober orders one (or both) of them without any real indication, and then they come back positive or borderline positive... just complicates everything....

And if you do enough tests, one of them will eventually come up positive, regardless of complaint/Hx...

 

[roja]

Yup. Hence..... Bonferroni!

 

[blz]

Stupid post. Are we all supposed to laugh at this guy? Is that what all the cool kids do at your med school? lol...

 

[Hard24Get]

Stupid post. Are we all supposed to laugh at this guy? Is that what all the cool kids do at your med school? lol...

agreed, the post is stupid. But what do you expect, a scholarly work? This is SDN...

 

[lankysudanese]

This stumped a third year last week.

wow. im so sorry that you have to work with such lowly mortals. im sure that you've never misdiagnosed anything, and never will.

but seriously, if you really want to show how brilliant you are, why don't compare yourself to your peers? see if you can get some of their pimping questions correct?

oh, and FYI: Dr. Bartlet (at least the famous Bartlet in ID) is not that impressive at all. just a heads up in case ur SDN username was the first sign of an admiration.

 

[DOanesthesia]

This stumped a third year last week.

What an idiot!! They should just kill themselves. Scum of the earth 3rd years.