A 13 year old girl with history of lethargy, joint pain and cough....

A 13 years old girl presented to accident and emergency department with a history of lethargy, joint pain and cough. Both of her parents are from Jamaica. Her problem started one month ago with an upper respiratory infection. She was seen by her family doctor and diagnosed to have a viral infection. She has a past history of skin rashes that was never seen by her family doctor.
On examination she has a palpable cervical lymph nodes of various sizes, a congested throat, generalized myalgia and a swollen ankle joint on the left side.
Her BP is 120/75 mmHg, HR 90 bmp, RR 22/min.
A urine test shows protein+ve with red cells.
other tests are as follows:
Hb = 9.7 g/dl
TLC = 4x10-9/l with neutrophils and lymphopenia.
Platelets =100x10-9/l
Retic count = 2.6%
CRP = 20

Questions:
1. Which three other investigations should be carried out?
2. What treatments should you prescribe?
3. What are three possible differential diagnosis?

Answers:

Anorexia And Fever - Case Study

A 22-year-old man presented with malaise and anorexia for 1 week. He vomited on one occasion, with no blood. He has felt feverish but has not taken his temperature. For 2 weeks he has had aching pains in the knees, elbows and wrists without any obvious swelling of the joints.
He has not noticed any change in his urine or bowels.
Five years ago he had glandular fever confirmed serologically. He smokes 25 cigarettes per day and drinks 20–40 units of alcohol per week. He has taken marijuana and ecstasy occasionally over the past 2 years and various tablets and mixtures at clubs without being sure of the constituents. He denies any intravenous drug use. He has had irregular homosexual contacts but says that he has always used protection. He claims to have had an HIV test that was negative 6 months earlier. He has not traveled abroad in the last 2 years.
He is unemployed and lives in a flat with three other people. There is no relevant family history.

Examination
He has a temperature of 38.6°C and looks unwell. He looks as if he may be a little jaundiced. He is a little tender in the right upper quadrant of the abdomen. There are no abnormalities to find on examination of the joints or in any other system.

Investigations
(normal values shown in brackets)
Haemoglobin 14.1 g/dL (13.3–17.7 g/dL)
Mean corpuscular volume (MCV) 85 fL (80–99 fL)
White cell count 11.5 × 109/L (3.9–10.6 × 109/L)
Platelets 286 × 109/L (150–440 × 109/L)
Prothrombin time 17 s (10–14 s)
Sodium 135 mmol/L (135–145 mmol/L)
Potassium 3.5 mmol/L (3.5–5.0 mmol/L)
Urea 3.2 mmol/L (2.5–6.7 mmol/L)
Creatinine 64 μmol/L (70–120 μmol/L)
Bilirubin 50 mmol/L (3–17 mmol/L)
Alkaline phosphatase 376 IU/L (30–300 IU/L)
Alanine aminotransferase 570 IU/L (5–35 IU/L)
Fasting glucose 4.1 mmol/L (4.0–6.0 mmol/L)

Questions
• What is your interpretation of the findings?
• What is the likely diagnosis?
• What treatment is required?

Answers And Discussion

Approach to Patient Presenting with Numb toes - History and Examination

A middle aged man has developed numbness and tingling in his toes and feet, and more recently his fingertips. He also complains that he trips up more frequently.

Clinical Approach: This man has distal sensory symptoms and motor symptoms.  Here it is important to decide whether this is due to a peripheral cause ,  central or a combination of both.

Clinical History :
1. Is this an urgent case? Ask about the duration of symptoms and rate of progression.  Any worrying associated symptoms like loss of sphincter control or difficulty in breathing.

2. Differentiating between peripheral and central nervous system dysfunction:

A peripheral nervous system dysfunction is characterized by

• tingling, numbness and burning in feet.  
• Numb fingers. 
• Foot drop
• Difficulty in rising from a chair
• Difficulty in going up and down stairs.  

A spinal cord lesion is characterized by

• Legs and feet feeling stiff and heavy. 
• Clumsy stiff hands
• Sphincter disturbances. 

3. Duration of symptoms may help determine the cause of neuropathy.  

4. Any associated pain.

Past History: Ask specifically about:

• Diabetes mellitus 
• Alcohol intake 
• Current medications
• Dietary history 
• Pernicious anemia 
• Hypothyroidism 
• Weight loss 
• Smoking 
• Neck trauma 
• Rheumatoid arthritis. 

Clinical Examination: 

1. Signs in case of peripheral nervous system disorder 

• Distal weakness 
• Absent ankle reflexes
• Stocking distribution sensory loss
• Muscle wasting (if severe) 

2. Signs in case of central nervous system disorder 

• Spastic tone
• Weakness both proximal and dismally, but predominantly in leg flexor
• Brisk reflexes 
• Extensor plantars
• Possible sensory level 

3. Is is important to check if the signs are symmetrical?

• Asymmetry in the context of an upper motor neurone syndrome would represent a Brown-Sequard syndrome with loss of proprioception ispilateral to the weak leg, and loss of pain and temperature sensation contralateral to the weak leg. 
• Asymmetric lower motor neurone findings suggest mononeuritis multiplex or entrapment neuropathic..

4. Check for associated cranial nerve pansies

• Deafness in CN VIII
• Bilateral facial weakness in Guillain-Barre syndrome and Sarcoidosis 
• Malignant infiltration of the basal meninges may lead to multiple cranial nerve palsies. 

5. General Examination :

Look and check if the patient is systemically well? 

• Cachexia may suggest malignancy or alcoholism 
• Vasculitic rash in systemic vasculitis 
• Look for signs of hypothyroidism 
• Check