jmj11 Posted May 12, 2018 Share Posted May 12, 2018 I can't think of any hard-to-solve cases right now. But does anyone else have one? If so, take us all on a guessing-figuring-out process. Let me throw out one, which is interesting, but not that difficult. I recently saw a 35 year old lady who had a neck-pain syndrome. No injury. But she had severe neck pain for about 10 days each month (around her menses) and no headache. She pursued this from a neck pain perspective and had multiple scans (moderate DJD but nothing more). She had multiple neck injections (facet joint) with no benefit. Then she saw a neurosurgeon who eventually did a cervical fusion. Still no help for her disabling neck pain for 1/3 of her life (the other 2/3, no pain). She was several medications (gabapentin, amitriptyline) with no help. So, she finally started to think that this may not be a neck problem. She, of course, was right. The neck pain was totally aborted with sumatriptan and when we worked up to 40 MG of nadolol, the number of days dropped down from 10 to 3 per month, easily treated with sumatriptan. The neck is often a referred area for migraine, but I can't remember seeing a case where the pain was exclusively neck. So, give us a more challenging case! Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 13, 2018 Share Posted May 13, 2018 I have one, 38yo F w acute pain of b/l lower legs and feet. No injury or fever. no history of joint swelling or pain. H/o pulmonary emboli post partum. She has been working in an office for 8mo and sits most of the time. No drug or ETOH abuse. PE: 2+ pitting edema of lower legs throughout, swelling causes a reddish hue to her skin, no varicosities noted, mod TTP of lower legs and pain w ROM of ankles. pedal pulses not appreciated dt pain. What would you order and what is your DDX? Link to comment Share on other sites More sharing options...
jmj11 Posted May 13, 2018 Author Share Posted May 13, 2018 US, Inferior Vena Cava for starts. Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 13, 2018 Share Posted May 13, 2018 Doppler venous U/S of b/l legs unremarkable Link to comment Share on other sites More sharing options...
lkth487 Posted May 13, 2018 Share Posted May 13, 2018 ESR/CRP? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted May 13, 2018 Administrator Share Posted May 13, 2018 MRI the low back looking for radiculopathy. Link to comment Share on other sites More sharing options...
GatorRRT Posted May 13, 2018 Share Posted May 13, 2018 How recent were the emboli? I would consider an echocardiogram to r/o right sided failure. Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 14, 2018 Share Posted May 14, 2018 ESR was 30. MRI of low back was not considered. Emboli had occurred five years ago Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted May 14, 2018 Share Posted May 14, 2018 If you're hunting for CHF/right sided failure, what about starting with a BNP? Does the edema lessen overnight when the patient is laying flat? Does she have any history of any abdominal surgeries? What's her BMI? Link to comment Share on other sites More sharing options...
thinkertdm Posted May 14, 2018 Share Posted May 14, 2018 The differential could include (forgive me, I just woke up): bilatal (pitting) edema: acute right sided heart failure, portal vein obstruction, acute renal failure, bilateral dvt (apparently already ruled out); less likely, hypothyroidism, lymphedema Pain: sunburn, increased skin turgor, new medications, polymyositis. And dog bites. Time for coffee. Start with metabolic panel, with alt, ast. Toss on tsh, though low yield. CBC too. As mentioned above, bnp, but if you have copd or hyperthyroid, or any kind of fluid overload state, will be high. Esr and crp, I like both. Please list meds both prescription and otc. Bmi. Smoking history. Travel history (consider travel related things if positive). The pitting suggests fluid. Is she dyspneic at any point? Orthopnea? I hate these guessing things... Link to comment Share on other sites More sharing options...
PACoors Posted May 14, 2018 Share Posted May 14, 2018 I had a fun patient, I will try to keep it short and sweet. I work in an ER btw. 30 yo male with PMHx of Bardet-Biedl Syndrome (he's legally blind, polydactyly, hypothyroid) came on for worsening RLQ pain that started same day in the morning that has been getting progressively worse. Saw PCP that morning, scheduled outpatient imaging later in the week, told to go to ER if pain got worse. Shows up to me. Vitals stable besides mildly elevated BP and a temp of 99.9. Exam unremarkable except for pretty decent RLQ pain and rebound tenderness. I'm thinking this is gonna be a quick lab, line, CT, appendicitis call the surgeon. Radiologist pages me, I pick up and say "Let me guess, appendicitis?!" Nope, he had a 7-8 cm venous thrombosis in his superior mesenteric vein causing secondary acute enteritis and edema in the bowel. Patient and family failed to mention that he is also getting worked up outpatient for Fatty liver disease, so I'm guessing he has some kind of coagulopathy that they haven't figured out yet. Why else would this person throw a clot in such an unusual place? Labs before starting high dose heparin came back with normal PT/INR but low PTT. Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 14, 2018 Share Posted May 14, 2018 7 hours ago, ohiovolffemtp said: If you're hunting for CHF/right sided failure, what about starting with a BNP? Does the edema lessen overnight when the patient is laying flat? Does she have any history of any abdominal surgeries? What's her BMI? Interesting that you guys are thinking about R sided heart failure specifically. CHF did cross my mind but ruled it out since she denied orthopnea, dyspnea on exertion, PND, h/o heart surgeries or problems. No h/o HTN or DM. So I did not order BNP or ECHO She did report some relief in the morning but not enough. Pain was pretty constant. No h/o abdominal surgeries. BMI 27 Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 14, 2018 Share Posted May 14, 2018 2 hours ago, thinkertdm said: The differential could include (forgive me, I just woke up): bilatal (pitting) edema: acute right sided heart failure, portal vein obstruction, acute renal failure, bilateral dvt (apparently already ruled out); less likely, hypothyroidism, lymphedema Pain: sunburn, increased skin turgor, new medications, polymyositis. And dog bites. Time for coffee. Start with metabolic panel, with alt, ast. Toss on tsh, though low yield. CBC too. As mentioned above, bnp, but if you have copd or hyperthyroid, or any kind of fluid overload state, will be high. Esr and crp, I like both. Please list meds both prescription and otc. Bmi. Smoking history. Travel history (consider travel related things if positive). The pitting suggests fluid. Is she dyspneic at any point? Orthopnea? I hate these guessing things... CBC, CMP, TSH, and UA normal. No meds. CRP was not ordered even though I should have. No smoking h/o. No recent travel. Link to comment Share on other sites More sharing options...
jmj11 Posted May 14, 2018 Author Share Posted May 14, 2018 You seem to be hinting at a acute inflammatory process. I skimmed the above (I'm with patients right now) and didn't see BUN/Cret but I'm sure were done . . . and normal? Early I was alluding to a inferior vena cava syndrome (not leg clots), which I've seen once with these symptoms, but is very rare. I thought of Erythema nodosum, but have never seen pitting edema with it, just the stereotypical sub-q leg lesions. Just thinking out loud. Doesn't sound like a pump issue. Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 14, 2018 Share Posted May 14, 2018 4 hours ago, jmj11 said: You seem to be hinting at a acute inflammatory process. I skimmed the above (I'm with patients right now) and didn't see BUN/Cret but I'm sure were done . . . and normal? Early I was alluding to a inferior vena cava syndrome (not leg clots), which I've seen once with these symptoms, but is very rare. I thought of Erythema nodosum, but have never seen pitting edema with it, just the stereotypical sub-q leg lesions. Just thinking out loud. Doesn't sound like a pump issue. Inferior vena cava is a possibility. Would signs show up on the leg U/S? Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted May 15, 2018 Share Posted May 15, 2018 U/S would probably not show on a lower extremity doppler, because that's just looking for flow and compressibility. I've seen CHF in folks without any of the s/s you quote in my current/former meth user patients. Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 15, 2018 Share Posted May 15, 2018 Ok I'll tell you guys the rest of the story. So the patient goes to the ER while doppler u/s and labs are pending because her legs were too painful. The doc there orders a chest CT angiography and repeats same labs and u/s. CT shows bilateral hilar adenopathy but he doesn't tell her. He just tells her they couldn't find anything and that she probably needs an X-ray of her ankles and sends her back to me. I give her a course of prednisone and boom her leg swelling and pain disappears. Anybody know the diagnosis? I am glad she got the CT at the ER because otherwise I think the diagnosis might have taken longer to be discovered. Will keep in mind inferior vena cava and acute CHF with future patients. Link to comment Share on other sites More sharing options...
JoeM Posted May 15, 2018 Share Posted May 15, 2018 Sarcoidosis? Link to comment Share on other sites More sharing options...
rawwrr342 Posted May 15, 2018 Share Posted May 15, 2018 5 minutes ago, JoeM said: Sarcoidosis? Ding Ding Ding Link to comment Share on other sites More sharing options...
jmj11 Posted May 15, 2018 Author Share Posted May 15, 2018 7 hours ago, mega525 said: Ding Ding Ding Thanks. That was great. Link to comment Share on other sites More sharing options...
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