If the explanation of any phenomenon should make as few assumptions as possible, eliminating those that make no difference in the observable predictions of the explanatory hypothesis or theory, why do I have a letter in my hand from a urology nurse specialist saying she does not think my patients’ weight loss and raised ESR are due to his prostate cancer?
I consulted DD, a 58-year-old gentleman I had seen a couple of times before. This was two weeks ago. He had been feeling generally unwell with earache and lethargy. He was also quite short of breath on examination. He had been diagnosed with asthma 2 years previously. There was nothing much to find on examination and he left labeled with another ‘viral infection, common cold’ illness and agreed with a plan of bed-rest and paracetamol.
His distraught wife rang two days later and explained he was much worse. His hands and felt felt numb and tingly, he was ‘off his legs’ and found it very difficult to support his own weight when going to the toilet. I visited.
DD was rolling around in bed, obviously anxious and hyperventilating. Cardiovascular, respiratory and gastrointestinal examination were unremarkable apart from a rapid heart rate and rapid respiratory rate. I could see a large urticarial (nettle) rash on his back which DD said was very itchy.
Sensation to touch and reflexes were intact in all four limbs. I did not check the power of various muscle groups except his grip, which was normal bilaterally.
Something was going on, even if just anxiety and hyperventilation (which can cause the tingling sensation). I decided it was time to reassure him and explain that, although I could not find anything obviously wrong, I would arrange some blood tests and review him with the results.
As I left, his daughter (also present during my visit) mentioned that he was on the waiting list for removal of nasal polyps. Could this be my old freind Churg-Strauss? No, it’s too rare. Surely not.
The district nurse took bloods the next day.
Total White Cell Count (10^9/L) = 45.6 (very high)
Neurophil count (10^9/L) = 16.4 (high)
Eosinophil count (10^9/L) = 25.1 (very high)
Erythrocyte sedimentation rate (mm/hr) = 4 (normal)
Plasma C-reactive protein level (mg/L) = 72.0 (very high)
I did not have the pleasure of admitting DD. But I did ring the registrar a few days later. A vasculitic rash had developed during admission and Churg-Strauss syndrome was diagnosed. DD is making an impressive recovery with 40mg Prednisolone daily and will soon start Cylophosphamide injections.
Imagine you are seated at a table with two bowls in front of you. One contains peanuts, the other tablets of the illegal recreational drug MDMA (ecstasy). A stranger joins you, and you have to decide whether to give them a peanut or a pill. Which is safest? You should give them ecstasy, of course. A much larger percentage of people suffer a fatal acute reaction to peanuts than to MDMA. …
from Spotty Deference.
It’s full on at this time of year for most GPs and I am no exception.
I’ve no space in my mind for reflective learning, looking at evidence etc.
So here is a quick wave to fellow bloggers and Merry Christmas.
Changes are afoot for 2009! See you then.
