Female patients: 43 age,weight 46 kg, height 165 cm, 86 pulses per minute, body temperature is constantly 38°C, normal lab tests, with high stress work environment, physical activity of moderate, persistent feelings of fatigue and sleep, without sugar and fat, blood pressure slightly lower than normal, with mild rheumatoid arthritis,any history of TB and other chronic infection.
At the age of 17 due to nausea and vomiting, seek medical attention and underwent surgery with the diagnosis of small bowel adhesions and a very small part of the small intestine is removed.
With dexamethasone for a period of six months after taking the patient's increased appetite and weight were normal.
What would you recommend for this patient?
From her BMI , can be defined as malnourished that would cause by many conditions such as hyperthyroidism, dm,malignancy, connective tissue disease such as sle ,mctd and chronic infection such as TB , AIDS.IN addition the major problem is incomplete history and physical examination in this patient can make us jump to the psycotic or mal nutrition cause.
mg+B6 4tab/day, xanax 0.25mg 1-2 tab/ day, regular time table for food, fruits and sweets(not in excess), AINS, 1 month, she's extenuate
Hair mineral analysis followed by nutritional supplements , modification of her life style + steroids
You should pay attention to risk factors for anorexia nervosa. It's a possibility. Give to us more clinical finds, like age and the exclusion of systemic / organic disease. Try to work together to: psychiatrics and nutrition, if possible.
From her BMI , can be defined as malnourished that would cause by many conditions such as hyperthyroidism, dm,malignancy, connective tissue disease such as sle ,mctd and chronic infection such as TB , AIDS.IN addition the major problem is incomplete history and physical examination in this patient can make us jump to the psycotic or mal nutrition cause.
Meditation & counselling is better . you mention high stress work environment so ask her to take a rest or change the work environment.
She should be investigated by infction diseases specialist, rheumotologist , and endcronology specialist.
This patient fits PUO think infection, malignancy,toxic effects of substances
check her thyroid status,crp ,abdominal U/s R/o possibility of felty's syndrome
is she on steroids?
if her CRP is high check for infectious pathology consider AIDS and TB (may have atypical presentations due to imune modulation)
if all came back normal start her on 50-100 mg voltarene for like 1-2 week with any PPi for stomach protection and see if the fever subsides
many patients with chronic disease esp. painful condition would have depression .anxiety may come from lack of response to treatment, fear of disability or "steroids" consider psychtherapy, longterm antidepressants but pass on the idea of fever comming from stress or anxiety
you may consider the diagnosis of manchausen syndrome if you can't document pyrexia in your clinic
though we don't know the age, the stressful environment may be one of the causes. would advise to take rest, and steroid therapy for RA (if she isn't already on it)
If there is signs of somatic disease I will suggest / an ex juvantibus/ approach with SSRI
Did you checked with the tongue? Whether coated or not ? also see that patient is giving history of constipation or not give some fibers into the food.. else add some mild laxative.. I am bit sure the feeling of fatigue and sleep will subside with the little raised temperature..
Sorry, If there is NO signs of somatic disease I will suggest / an ex juvantibus/ approach with SSRI
Stress due to overwork.rest, nutritious diet and physical rest with symptomatic treatment.
F/U on her Rheumatoid Arthritis. How is it being treated? Are her meds correct; is she taking them properly?
Do thyroid tests.
Consider a sleep test for sleep apnea.
Check on her psychiatric status (depression, anxiety)
Did you do a CBC and iron studies to check for anemia?
Talk to her about her eating habits/nutrition.
Check thyroid, glucose levels, nutritional intake for 2 week , level of activity with "mild" rheuatoid arthritis. F. Campbell, NP
Eliminate tuberculosis, deep cancer, hemopathy, or connective tissue disease before considering depression...
Chronic fatigue syndrom...SSRI along with NSAID for a week. Also take detailed history to reveal menopausal symptoms.
Make sure a full thyroid with TSH, T3 & T4 all. Center of the normal range as well as checking for SLE
Sometimes TSH will be read as normal but if on the extreme edges for a patient with autoimmune disease this can be misleading
Antonia Scott
First of all we need to check her thyroid function test and then should have an evaluation from psychiatric physician. How about her gynae things? You mentioned mild rheumatoid arthritis how do you categorized that?
Do you feel happy, take sound sleep, laugh, can express and communicate freely to let out your feelings, have good appetite, bowels move every morning, you reach out to your goals of achieving things and to know yourself, and have free mind and heart to think and feel? Check all this honestly and reveal to your confident one.
Best wishes, Dr. Ajai Singh
Where she is living? Is there any manifestation of inflamatory bowel diseases, malabsorption.How her bowel motions?How her BP? serum electrolyes, calculated GFR, serum Fe, TIBC, check her ESR ,CRP,RF,AntiCCP3,ANA. If all within normal then one may resort to approach with SSRI
The data is not sufficient for diagnosis; she is below normal weight and she may suffering from chr. infection
to rule out SLE, hypothyroidism and TB
Quite often the women have some subfebrile condition but in these cases the body temperature is around 37 celsius. 38 sounds quite high for me. I consider firs hypersedimentation, leukosyte level (and leokosyte cell count), c-reactive proteine, thyroxin etc. good clinical inspection (e.g. lymb nodes), thorax x-ray and upper abdomen Ultrasound examination.
It seems that there is something somatic disorders (e.g. malignancy, hyperthyreoidism, and as told before in this response chain mayby also rheumatoid arthritis which is not proberly treated
Psychotherapy, analgesics and antipyretics for joint pain and measurement of body temperature. Rechecking and Essam of blood and urine after a week of rest
I'm agree with the colleagues that recommend to study, in first place, the thiroide function, diabetes mellitus, tuberculosis and connective tissue disease. But, I think it’s also important to know what the patient thinks about those symptoms.
Please, tell us what the final result was. I’m anxious to know it.
Eliminate all caffeine from her diet, and after one week of headaches she will be better, including from the rheumatoid arthritis.
Needs BT with electrolyte maintenance IV drip with multivitamin in drip.
From my experience, I insist in withdrawing ALL caffeine from the diet and after one month the good results will appear.
The caffeine causes around 500 distinct sicknesses. It is nearly unbeliavable its range. But advice her of the first week of headaches caused by the caffeine withdrawal.
first I should ask the patient if she is willing to accept a medical to talk, and - except in cases of emergency - in affermative case we could speak directly toghether. so it would became possible to know the age, the country or city, and also her history, and to ascertain the fisical and mental situation (her obiective status) and I would ask her if she is willing to accept also a speak with her relatives or general practitioner, in order to understand what is possible or duty to do....
You know I respect all the things that all of you scientist or phisician is talking about but I agree with Dr or Mr Ajai Singh. You don´t need all kinds of exams if you see all the things together, their body their soul! A body can talk for itself. This is the reason why I really believe that this patient can be sucesfull treated with Acupuncture and Chinese Phytotherapy because this is a typical syndrome of deficiency of Xue that came from a Pi Deficiency, stress, fatigue, want sleep, immunologic system imbalanced...and probably much more things about feelings...
You know there is more than 4.000 years of Chinese Medicine and bilions of people are treated with that in China for a lot of years. Believe me this work very well is cheap and don´t need all this tecnology probably is the reason why some physicians don´t want to believe in that!!! But works!!!
It really works!
It is neccessery to take lab analzses Thyroxin,Triiodthyronin and Thyreostimulin because it could be some kind of hyperthyreosis.After dg. the treatment is very effective.Markontic
How old is she? What is "without sugar and fat"? Which lab tests are normal? Is she losing weight, or, has she always been that slim? does she have a diagnosis of mild rheumatoid arthritis (RA) or just the symptoms? Anyway, my first dg hypothesis: Addison's disease, hyperthyroidism, the RA itself, chronic infectious disease, cancer, depression.
47 Year female on HAART therapy since 5 years,h/o cramps+.it is better she should undergo venous duplex scan to r/o deep venous thrombosis.
Once I told it looks like a hyperthyreosis.Diagnostic is very easy and the treatment even easier if you made a good diagnostic.Try earlier recommanded lab analyses and send me the results.I will say you what to do further.Markontic
Should steal some time for self where she should meditate, relaxing exercises and do some PRANAYAM (breathing exercises). this will improve her sleep and cardiac function and ultimately rheumatoid arthritis, an autoimmune disease. she can take some additional exercise for joints.
take a day of from work. GO FOR a stroll.
she NEEDS A FRESH AIR to calm her self and go a bit of socializing family or close FRIENDS
I would recommend to inform the lower limb venous doppler,so that, treatment could be recommended.
Meditation and soft protein rich foods and check for essential micronutrients may help in this case...
What was her healthy (baseline) weight? Does onset of underweight/ fatigue happen fast/slow, coincide with anything else mentioned in her pt. profile? What are her TFT's? Has she been evaluated for depression? What is her blood sugar and eating habits Nausea? Anorexia? A careful history will tell you where to look. please keep me informed of her progress
I think TB could be a possibe diagnosis or even broucellosis if the presence of arthritis was not RA
The patient is imunocompromised ( does she take any medications for RA?) and also have some neurologic simptoms. What about neurologic examination? Should also consider evaluation of inflamation disease of CNS.
I would want to knw her complet histry and also wants to knw her age and she is in anxiety i think.
Furthur i would want to knw about menstural histry ?and is she menopausal or nt.then will decide
There is more to be followed up from the history. Easy fatigability, persistent feeling of sleep, stress and slight hypotension may not be enough in some cases. Also I will need some other investigations to reach to my destiny. But your opinions are awesome and that's what am going for to help understand this case.
chest X ray to be done and ultra sound of abdomen. RA it self can lead to fever but look for tuberculosis as patient might be on steroids
Pain medication and other arthritis treatment could help, adequate rest is also therapeutic; preferable massage- this would do best for anxiety and stress factors.
for how long these symptoms present? any weight loss? are they recurrent ? ESR?
Especially with chronic disorders, start with simple solutions that cost the patient no money, and require no more doctor visits. Then work at making yourself useless as soon as possible so patients can get back to functioning as normally as possible on their own. Finally, always recommend treatments that you are qualified to make by credentialing or vast experience and that hve a high likelihood of returning the patient to optimal functioning.
As was mention before the medical and physical history is incomplete...how old is she? she still on reproductive age?
...even the possible diagnosis can be: ...malnutrition, TB, mild rheumatoid arthritis?, psycotic?...if she is pregnant the basic pathology can be deterioriate for the "new" hormonal situation.
I see that we, all together, could finally build a new hospital to have a diagnosis for this patient.
I advise to follow her conditions step by step, taking into considerations all procedures results and therapy success or failure.
Let us Know!
Bye
R
I think she needs a pr oper nourishment no doubt, but its important to know her psychological states by the counselling, then we can make a treatment plan according the need.
She has to get some vacations to start, but also psychological assessment and exclusion of organic disease.
May be anorexia nervosa? What is her thyroid status and ultrasound examination?
Looks to be a case of persistent over stress.Multi vitamin with BD dose of tablets of propranolol & antianxiety 'll suffice.
I'll recommend the study of thyroid function, dm and TB. Meanwhile she must do physical rest and nutrious diet with symptomatic teatment. What was the final diagnosis?
FUO one should first rule out infection and could do work up suggesting connective tissue dse, autoimmune prob and malignancy
Normal lab. parameter should think except condition such as infection, connective tissue and malignency. Other disease such as physical and psycotic conditionmust check ...
I think examinations such as MRI from head and neck or vestiboular system of iner ear wil be check
What do u mean by-normal lab.tests?Does it include normal CBC,PBS,full biochemistry profile.Lastly,what is her pulse during sleep & what is her thyroid profile?
If all laboratory parameters are normal and no specific condition suspected, then it could be manifestation of her high work stress.
Need is of detailed history,exam & through lab.At sametme role of psychatrist is to b taken...
The women needs thorough medical examination with tests along with a psychiatric evaluation, as people with chronic medical illnesses tend to have secondary depression
I will sugest you to try N terminal sequencing. It can give you some infomation about unknown proteins or peptieds. But you need have a pury sample.
remarkably no one has suggested any treatment protocol to address the obvious patho-physiological mechanisms associated with stress, and chronic inflammation and RA (mild or not). I would like to see less suggestions of tests and more suggestions of treatment, after all the question was "what would you recommend for this patient as in how would you treat this patient to effect a positive therapeutic change...more tests is not treatment...and will not create any change that will positively impact the quality of life of the patient. Finally other than thyroid test ( i agree), Testing is fine but it rarely if ever resolved a problem.
How do you suggest a treatment when you dont have idea about the diagnosis, Dav id?.
Look´s like you use "Dr. House" method ?.....start with a treatment, wait for the effect and change if the patient dont improve. The diference is than in TV, is faster and "Dr. House" can solve the case in 40 minutes. !
The diagnosis is right in front of your face. I looked at it at figured a "direction" to start that is non-toxic and did the patient. One Diagnoses the direction to proceed. What was suggested were "fishing' expeditions" and rule outs...not bad ideas in the case of a severe symptomatic presentation, but this was fairly simple and a course of treatment could have been initiated without committing a specific direction as we treat upwards...not diagnosis downwards...not as obtuse as one would think if you read it as few times. BTW my nickname is Dr House because i can diagnoses quickly and accurately among colleagues, and yes this is not TV, so lets cut the posturing and the covering our tracks and start treating. So my challenge is simple, what would everyone do now, if they had nothing more to go on :)
About female patients I recommend try to low stresswork environment through meditation methods like yoga excersises , sleep 7-8 hours per night, take your time once a day, because can be a fatigue chronic sindrome.
The Chronic Fatigue Syndrome is caused by the real fatigue added with the caffeine.
Withdrawing the caffeine, the patient cures.
More details in the e-book “Fluids Hypertension Syndromes”, available free at www.izecksohn.com/leonardo/ .
What is needed is a good clinical evaluation (proper history, physical examination)- after that only other options to be discussed. Conditions which present like this are Hyperthyroidism, Tuberculosis and other chronic infections and lastly psychiatric problems
Dr.P.K.Sasidharan
Calicut Medical College
Did you consider any malnutrition like Celiac disease?? After decades of inflammation in the small bowel it goes ahead with deficiency of almost anything of importance (Fe, Zn, Se,...) and so produces chronic symptoms like fatigue and even psychotic symptoms. Of course suffering around the clock on mysterious diffuse weakness produces lots of stress in the attempt to fulfill the daily normal programm.
PS: I do remember these bad years quite well... before the correct diagnosis by anti-tissue-transglutaminase-AK and biopsies of duodeneum, followed by lifelong glutenfree diet. This helped me to gain 10 more kiloes in the following 15 years, to enjoy my better nerves and to live with more power!
You can find 1 million links for CD!! one good short version is here:
http://digestive.niddk.nih.gov/ddiseases/pubs/celiac_ez/
Celiac disease is an immune disease in which people can’t eat gluten because it will damage their small intestine. Gluten is a protein found in wheat, rye, and barley. Other names for celiac disease are celiac sprue and gluten intolerance. When people with celiac disease eat gluten, their body’s immune system reacts to the gluten by attacking the lining of the small intestine. The immune system’s reaction to gluten damages small, fingerlike growths called villi. When the villi are damaged, the body cannot get the nutrients it needs.
Celiac disease is often hereditary, meaning it runs in families. Adults and children can have celiac disease. As many as 2 million Americans may have celiac disease, but most don’t know it.
Symptoms of celiac disease include
•stomach pain
•gas
•diarrhea
•extreme tiredness
•change in mood
•weight loss
•a very itchy skin rash with blisters
•slowed growth
Some people with celiac disease may not feel sick or have symptoms. Or if they feel sick, they don’t know celiac disease is the cause. Most people with celiac disease have one or more symptoms. Not all people with celiac disease have digestive problems. Having one or more of these symptoms does not always mean a person has celiac disease because other disorders can cause these symptoms.
Celiac disease can be very serious. It often causes long-lasting digestive problems and keeps your body from getting all the nutrition it needs. Over time, celiac disease can cause anemia, infertility, weak and brittle bones, an itchy skin rash, and other health problems.....
The only treatment for celiac disease is a gluten-free diet!!!
So, it looks very similar to this patients symptoms - ??
Even the Rheumatoid Arthritis can be explained by the permanent auto-immune-over-reaction with constant inflammation allover. And by the damaged GUT-microbion, which is also one component of RA! And so on....
Celiac (coeliac) disease (gluten enteropathy) (sprue) (collagenous-lymphocytic colitis): Coeliac disease is a genetic digestive deficiency. Meanwhile, the caffeine worsens it, besides causing many other signs and symptoms, mainly neurological ones. Our patients with congenital coeliac disease lessened their symptoms when stopped their caffeine ingestion. More details about the caffeine's sicknesses, on "Fluids Hypertension Syndromes", free at www.izecksohn.com/leonardo/ .
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