Well, CBC, Renal Functions, and UA to start with along with an MRI of the renal system. Also, can you describe the rash in more detail for us? ETA - What antibiotic was he switched to? And how long ago did he first start on the amoxicillin? I'm worried about possible serum sickness (Merck). Also, what are his vitals?

Check with his mother if he's been eating doughnuts with yellow icing. My son twice came out in a rash only on his lower legs after eating yellow-iced doughnuts when he was a toddler. Actually, just check anything he's eaten in the past week that's different to usual.

WARNING: There's a link to a picture of a rash in this dialogue! If you can't handle the rash, don't click the link! Arizonamyrie: What's his CBC? How is his renal function? Get a urinalysis! And-- K-Haldane: Has he been eating any doughnuts with yellow icing? (Everybody stops and stares) K-Haldane: My son twice came out in a rash only on his lower legs after eating yellow-iced doughnuts when he was a toddler. (The staring continues) House: Ookay. Welcome to DDx, K--may I call you K? K-Haldane: Well, I'd really prefer-- House: K it is! So Chai, what have you got for me? Chai: Well, we've got test results and some new symptoms--which would you like first? House: Oh, by all means, the symptoms! Chai: Well, the rash is now blistering and has just a teensy bit of necrosis. Arizonamyrie: What does the rash look like? Chai: Kinda like this. House: Ahh, I love purpuric rash in the morning. And it's got necrosis? Well those aren't really his legs in the picture, but I'll take it. The new symptom? Chai: Kid now has pain in his left elbow. House: And the tests? Chai: We have hematuria and proteinuria: creatinine clearance was at 31 with proteinuria of 4.5, but his blood urea was normal. House: Besides, y'know, that some of his blood was IN his urine. Arizonamyrie: He has a UTI anyway, hematuria isn't uncommon. By the way, what antibiotic did they switch him to? Chai: Cipro. Arizonamyrie: Could that give him serum sickness, you think? House: Practically unheard of for amoxicillin. Only 10 cases in 13 years. He's been fine on the cipro. So what have the blood tests shown us? Chai: CBC revealed normal WBC-- House: Sí! Chai: But he has hemoglobin of 95g/l. He has negative ANA and his C3 and C4 are normal. Arizonamyrie: I still want my MRI... Chai: Well you don't get it! I am sick of people sticking patients in the MRI of DOOM before trying an x-ray, ultrasound, or CT scan. You don't give MRI's out like candy, folks! This is the Diagnostics Department! What would you do if you couldn't get an MRI? Would you just DIE? Would you?! (Everybody stares again) Chai: (mumbles) He can't get one anyway. Has a frickin' cochlear implant. House: 어색한... (awkward...) (A/N: MRI wouldn't have shown anything anyway)

But he has hemoglobin of 95g/l. Just wanted to clarify a value - g/l - is that as is or supposed to be g/dL or something else? If nothing else, convert it to mmol/L. As for the imaging, let's do a renal ultrasound. Safe, somewhat effective, noninvasive, and cheap. Not too sure what we can use beyond that with a cochlear implant. Also, how is the kid's heart doing? The increased creatinine clearance and hemoglobin can be indicative of the ticker. Can someone listen to it for a murmur or irregularity? Also what were his vitals? BP, HR in particular?

Arizonamyrie: (suspicious) Is his hemoglobin really 95 g/L? Are you suuuure you don't mean 95 g/dL? Chai: Did I say 95 g/dL? No. I said 95 g/L. If it makes you happy I'll say it's 9.5 g/dL. Happy? Arizonamyrie: (to K-Haldane) I think she's still cranky about the MRI. (Out loud) Okay, since we can't get an MRI, let's get an ultrasound of the kidneys. Random Uncle: It's the ankles that have the rash, why look at the kid's knees? (Chai, Arizonamyrie, K-Haldane, and House all stare at the introduction of that guy at the family reunions who makes terrible puns. He promptly *poofs*) Chai: We have some renal enlargement. Pretty serious, and I'm having trouble with corticomedullary differentiation due to edema. Arizonamyrie: By the way, how is the kid's heart doing? The increased creatinine clearance and hemoglobin can be indicative of the ticker. Chai: The hemoglobin was normal, NORMAL dammit! I don't like counting in decaliters. House: I think we have finally found somebody crazier than Rabies chick. And she works here. Chai: Anyway, his heart seems okay. He has a blood pressure of 130/90, which isn't great, but his heart rate is around 70, which certainly isn't bad. I think you want to check out this new symptom. House: What? He's unhappy with the current state of his scrotum? Chai: No. He's coughing up blood. We have pulmonary hemhorrage.

Chai: Did I say 95 g/dL? No. I said 95 g/L. If it makes you happy I'll say it's 9.5 g/dL. Happy? Thank you. My brain has been incapable of math for the last seven days. I'm thinking Henoch-Schönlein Purpura. Can we check the IgA levels?

Yep. What she said. *ducks away and pretends she understands*

Chai: *returns with a tan from San Diego* What did I miss? Arizonamyrie: My diagnosis. The kid has Henoch-Schoenlein Purpura. House: And it's so spiffy it has to go in italics. March301: *raises hand* I think it is too! I do! I do! Arizonamyrie: Check the IgA levels. Chai: Immunofluorescence found granular deposits of IgA and C3 in the mesangium. Even a little IgG and properdin around. We have Henoch-Schoenlein Purpura. The pager to you, Arizonamyrie! Good job!

I'm back! This is my first chance to check these boards since Friday. I should have time for the pager, but if someone can post a case before I do, then they can have it.

Okay, I didn't want the differential thread to die, so I'm taking the pager again, I guess. CHAI: I have a new case! Patient presents with fatigue, headache, and fever. HOUSE: Don't they have a word for that out in California? I realize that it's so nice and warm out there, but here, we call that sort of thing, strangely enough, a cold. CHAI: I think you should take a loo--*pager starts beeping* HOUSE: Maybe it's a new case. Is this one more interesting? CHAI: No. Same guy. He just had a stroke.

Glad to see there's a new case, I'll join in after I've slept (lost a patient under my care at work tonight). I'd like to ask, as a moderator, that we try to abide by the following. From the initial post: When presenting a case, one must include: –Symptoms –Onset of Symptoms –Patient Gender/Age –*NEW* CBC/Chem-7 results –*NEW* Vitals –*NEW* Patient History These guidelines were developed over the course of the game previously as everyone asked for these five things initially, and it saved time. Also, on the show, the Ducklings usually have access to this when they are working on their DDx.

Sorry, forgot. Here we go: Patient is a 19 year-old black male Symptoms: -Fatigue -Headache -Fever -Stroke Patient says symptoms began about three days ago. He came into the clinic when he thought that a cold would have gone away by now, but he wasn't too distressed because it was a low-grade fever with occasional spikes. CBC revealed elevated white count as well as an elevated SED rate. SHx Patient denies alcohol and IVDA, but a nurse reported that he appeared to be under the influence. The clinic doctor ordered a tox screen, which came back positive for alcohol. Patient denies homelessness and is well-dressed. Patient was hypertensive at admission, but vitals were stabilized after the stroke. Patient's vitals are holding steady. I'm sorry about your patient, arizonamyrie. That really sucks.

The Game: I'm more concerned about the stroke right now. Contrast MRI to check for clots/bleeds so we can treat accordingly. Thanks Chai. We had four other pass since I started there, but he was my first under my care for the shift and my first while I was working. It's just eerie and surreal when it happens. Needless to say, I slept awful last night and am in this daze today. I didn't know him as well as another person who passed earlier this week - who I had mourned a bit on Saturday driving home. I knew when I started there that this would be the toughest part of the job, but necessary as it's unavoidable in a nursing home. My coworkers were awesome last night and really eased me into everything, and gave me time/space to cope.

ARIZONAMYRIE: We need an MRI. CHAI: MRI found a clot. We dissolved it with heparin. The kid's way too young to be having a stroke; something must have caused it. HOUSE: And whatever it is, it's making him worse. We have to try something, or the kid will die. ------------------------------------------------ Try taking 568 cc of ice cream. I hope you feel better.

568 cc of ice cream stat? That works - Ben and Jerry are my rarely-seen friends after a bad night. And I think I found the article you're using Chai - I just can't find a way to access it. Meanwhile, can we check his heart for an atrial myxoma or other defect/tumor? That could be throwing off clots, and could explain the fever.