Question

A 49 year-old Hispanic female came into your 24-hr Emergency care clinic complaining of purpuric lesions on her left and right ankles. She stated that she was being treated for rheumatoid arthritis with leflunomide and steroids.

1.What is your initial differential diagnosis? Give at least three. You begin to take a patient history and review of symptoms. She is originally from Venezuela but moved to the United States before Hugo Chavez and Nicolas Maduro came to power, and she has not returned in over nine years. She has lived in South Texas for eight years with her husband and two children. She is not on blood thinners such as warfarin (Coumadin). She denies use of alcohol, tobacco, or illicit drugs. She lives in near the bay but states she has not gone to the beach or been on the water for over five weeks. She has not eaten raw seafood in the last four weeks. She denies any known drug allergies

2a. What conditions might you now exclude?

2 b. Why can you exclude these? The patient had rhinorrhea and myalgia. She stated she had no sore throat, shortness of breath but a sporadic cough, felt no fever or chills, no nausea, vomiting or diarrhea, no abdominal pain, no leg swelling or pain in the extremities. Examination revealed temperature of 38.1°C, heart rate 106 beats per min, BP 126/68 mm Hg, respiratory rate 16 breaths per min, and oxygen saturation of 98%. Lungs were clear on auscultation. Her White blood cell count was 4600/microliter (normal 4500-11,000) lymphocyte count was 700/microliter (normal 1000-4800). Her electrolytes, kidney and liver function tests were within normal range.

3a. Do these findings allow exclusion of some of the differential diagnosis possibilities, and suggest some other possibilities?

3b. What other tests would you perform? The patient was given nucleic acid amplification tests for COVID-19, influenza A, and respiratory syncytial virus—all were negative. She was sent home with fluticasone nasal spray, with the diagnosis of sinusitis. She returned two days later, complaining of shortness of breath. Her oxygen saturation had decreased to 94% .

4. What possibilities must now be considered? List at least four. Radiography of the chest revealed a 5 cm mass in the left lower lobe. A CT scan revealed ground-glass opacity, and some left hilar lymphadenopathy.

5. What conditions from question 4 should be included? Patient now had a temperature of 39oC, complained of a productive cough with green sputum, weakness, nausea and vomiting. The heart rate now increased to 115 beats per minute, BP was 138/85 mm Hg. Auscultation revealed crackles in the left lower lobe. Oxygen saturation dropped to 92% within the two hour wait in the emergency room.

6.a. What are the most likely conditions the patient could have?

b. What should your next steps be with this patient? 2 pts c. What is your final diagnosis?

Answer 1

1) Purpura is the subcutaneous hematoma whose size ranges from 0.3-1 cm.

Differential diagnosis

if the purpura is palpable : Henoch- Schonlein Pupura , Rocky Mountain spotted fever, Acute meningococcemia , Gonococcemia

non palpable localised pupura : cutaneous disorders , iatrogenic purpura ( glucocorticoid use) , livedoid vasculopathy

generalised purpura: thrombocytopenia ( immune thrombocytic purpura), haemophilia, scurvy , ehlers Danlo syndrome

2a) we can rule out cutaneous disorders and iatrogenic purpura , scurvy and collagen defects ( EDS)

2b) since she has no drug allergies and has not taken blood thinners

3) a) low lymphocytes and increased temperature suggests infection

3b) we should check the platelet count , bleeding time inorder to rule out ITP and haemophilia.

4) Adenocarcinoma , squamous cell carcinoma and large cell carcinoma , infections , interstitial lung disease , pulmonary edema , pneumonia.

5) indicative of cancer as a mass is seen in left lower lobe

6) Any of the listed carcinoma

b) Biopsy should be done and oxygen should be supplemented

Diagnosed as lung cancer