Differential Diagnosis for...Whatever You Want

You said CT scan and ultrasound were both clean for the gallbladder so what weren't they clean for? My thoughts exactly! The vast majority of the differential will show up on an abdominal CT. I'd like to know everything that's on it. Could still be something renal; chem-20 doesn't show everything. Renal artery dissection, perhaps, or pyelonephritis. At any rate, I'd like a urinalysis to check for the latter, while looking for the former on the CT along with the kitchen sink. Familial mediterranean fever is still possible, so check. Longshot is referred pain from the pancreas; get her lipase and amylase. Still on the table is echinococcosis, so a serum echinococcal antigen would be nice. But the things in the right upper quadrant remain liver gallbladder, and the bile ducts. Fever and white count=-itis of some kind. Repeat the CBC and let us know how high the white count is. Also, repeat LTs and give us EXACT values. Just to rule a few more things out, chest x-ray. And an ANA with the latest bloodwork (because it could always be lupus). Differntial diagnosis au TARDIS!

Okay, I left home at 6:45 AM for college, and then work, and I just got home and it's 12:15 AM. We were short two people and the nurses in the previous shift gave laxatives/suppositories (and I had total cares for about 14 people to do). Plus, I need to see Silja's post again (I looked at it during microbiology to stay awake). So, if I really had a TARDIS (in real life) - I'd hop in, sleep for awhile, and pop back out to make this post. But instead, it will have to wait until later this morning (guh - it's morning already?) after I get my microbe-soaked (and one guy peed on me - the same one who had a conversation tonight with the guy who passed away two weeks ago under my care - Chai, the Ben and Jerry's night) scrubs off, get cleaned up, and go to bed.

Well, we can't get you a TARDIS, so let's wait until the morning for your post, okay? Feel better!

Shower helped. But you lot and your tests that I googled until about 2 am CST! My internet connection conked out before I did. I think it's accurate. Silja - good to hear that India went well, minus the dysentery. So, it sounds like your trip was a larger, messier version of tonight. ~~~~ Silja: Never stain or wrinkle again? What on earth did you do to it? Burn it? arizona: Burn --- coat in a layer of thin metal from, same thing (hey, when you've got a TARDIS to do laundry in, you might as well take it for a spin!). Good to see you back. Got any new ideas about how to thwap Chase? Silja: Not that I can discuss at the moment, but I do have to ask you to run a tuberculin skin test. TB can show up in the weirdest places and with the weirdest symptoms. And it takes a while so do shove her arm in the TARDIS and get me the result. And please test her for antibodies to coxsackie B. And You said "CT scan and ultrasound were both clean for the gallbladder," so what weren't they clean for? Chai: My thoughts exactly! The vast majority of the differential will show up on an abdominal CT. I'd like to know everything that's on it. This could still be something renal; chem-20 doesn't show everything. Renal artery dissection, perhaps, or pyelonephritis. At any rate, I'd like a urinalysis to check for the latter, while looking for the former on the CT along with the kitchen sink. arizona: Ah, I withheld information in the hopes that someone would ask, and you both did. Kudos. They were clean for everything that I could see. And radiology too - they looked at it after I told them about House's wardrobe - wouldn't give me the info unless I did. Silja: And are all the previous symptoms coming back or is it only fever and headache. Recurrent fever makes me think of a whole host of tick- and food-borne infections but almost all of them come with some sort of rash – so has her skin looked weird at any point? arizona: I asked the nursing staff more about that after I checked in on her earlier. They said that the symptoms were returning all together, rather than one or two at a time. I also noticed that she had a problem with some stiffness in her neck. Chai: There's more. Familial mediterranean fever is still possible, so check. Longshot is referred pain from the pancreas; get her lipase and amylase. Still on the table is echinococcosis, so a serum echinococcal antigen would be nice. arizona: Check, check, and check - that'll be the TARDIS for both of you tonight. Chai: But the things in the right upper quadrant remain liver gallbladder, and the bile ducts. Fever and white count-itis of some kind. Repeat the CBC and let us know how high the white count is. Also, repeat LTs and give us EXACT values. arizona: … Chai: Just to rule a few more things out, chest x-ray. And an ANA with the latest bloodwork (because it could always be lupus). arizona: So to recount - TB skin test, Coxasackie B Antibodies, UA, Lipase/Amylase, Serum Echinococcal Antigen, CBC (repeat for WBC), not exactly sure what Chai meant for LT (but I'll repeat the Chem-20 instead), Chest X-Ray, ANA, and check for Familial Mediterranean Fever. Okay. Good thing I have a TARDIS. Chai: Yup. Silja: Good thing you do. Cause we're going home to sleep. Chai: And it looks like you're not. arizona: Ugh! The following morning, after everyone has slept… House: Good morning Sunshine! arizona: Ugh. House: You look a little tired. arizona: Stupid TARDIS stranded me on a desert planet for three days, being chased by wild monkeys while it ran the labs for us. the Doctor: I got you back eventually. arizona: Yeah. We'll talk later Martian Boy. the Doctor: *shakes head, whispers* I'm not from Mars. House: Why's he here? arizona: Eye candy. Capt. Jack's back there too. Capt. Jack: You're hot. Wanna have a go at it? House: Wilson would be jealous. Capt. Jack: He could come along for the ride. arizona: Enough space twerps. Silja: This is nice, but Chai and I didn't have the best nights sleeps ever just to hear you talk about your misadventure. arizona: Right. Here are the labs: **TB Skin Test: Two step test. 2 mm induration, 6 mm induration respectively. Coxasackie B Antibodies: Negative UA: All normal Lipase/Amylase: Normal/Normal Serum Echinococcal Antigen: Negative **CBC (repeat for WBC): WBC is 24,000. Also, **elevated monocytes LT (but I'll repeat the Chem-20 instead): All normal - see next six lines ----Alanine transaminase (ALT) 26 ----Aspartate transaminase (AST) 32 ----Alkaline phosphatase (AlkPhos) 134 ----Total Bilirubin 0.9 ----Direct Bilirubin 0.1 ----Albumin (ALB) 4.4 Chest X-Ray: Clean **ANA: 1:160 Check for Familial Mediterranean Fever: Clean. arizona: Did I miss anything? House: Yes. The bill for the new wardrobe. And a trip in the TARDIS to get those vintage t-shirts back that you ruined. arizona: Chai, did you mean ALT before but the keyboard skipped the "A?" House: Three and six? arizona: Two and six. Still technically negative - unless you're a health care worker. House: Borderline if you're sitting in this office right now. Chai: The ANA was positive though. House: It's not Lupus.

It's not Lupus. It never is. Nuchal rigidity=do an LP. Be sure to let me know whether the fluid pressure was high. The elevated monocytes suggest something viral--put her on acyclovir and corticosteroids. Sorry. My hospital just calls them liver tests now, so LTs rather than LFTs. I'll switch it back. If the symptoms returned, they had to have gone away at some point. What was the timeline on that? And by the way? Capt. Jack+House+Wilson=ChaiSQUEEE!

Chai:It never is. Nuchal rigidity=do an LP. Be sure to let me know whether the fluid pressure was high. The elevated monocytes suggest something viral--put her on acyclovir and corticosteroids. House: Good to see that you finally got that bit of information. arizona: Who first did the physical? House: *looks away* arizona: I thought so. Chai: Sorry with the "LT." My hospital just calls them liver tests now, so LTs rather than LFTs. I'll switch it back. arizona: Up to you. I usually try to shy away (at least a bit) from the medical lingo. Chai: If the symptoms returned, they had to have gone away at some point. What was the timeline on that? House: Oh all right, I'll tell. Symptoms waxed and waned over two weeks, then she came in here after her friend was concerned about her not eating. Then, like every patient of ours, the symptoms returned. arizona: Let's go do that LP. after Chai, House, Wilson, and Capt. Jack took a trip in the TARDIS… Capt Jack: Was it as good for you as it was for me? House, Wilson: Guh! Chai: *still squeeing* (somebody ought to write that as a fanfic) arizona: And they're spent. Capt. Jack: Yup. Still got it. the Doctor: You never lost it. Capt. Jack: You're just jealous. arizona: Okay you love birds. LP came back. It looked clear at first, but it wasn't. White cells were 176/cc^3. Most were mononuclear cells. Protein triple the normal values, and glucose half. It's some sort of meningitis, but we don't know which yet, and we won't know how to treat it. Silja: The mononuclear points to viral, but the protein points to bacterial. arizona: *staring at the boys* And if House was capable of coherent speech right now, he'd be berating us over how close we all are. Maybe we should repeat a few of these tests, or pursue a few of them more in-depth.

You still got the spinal fluid? Good, then run viral cultures on it. Also check for pleocytosis. Repeat the cultures--maybe bacteria will show up this time. Just for funsies, check for mouth ulcers. Also, get an opthomologist so we can check for signs of Vogt-Koyanagi-Harada syndrome; she may be in the meningoencephalitic stage. At this point, we have half a diagnosis. We just need to find underlying cause.

*walks in and starts cleaning the windows in diagnostics* I'm not even smart enough to understand this game on a small scale, but I wanted to play so I opted to be a janitor.

Well Jen, welcome. And remember that House episode where he said how/when he wanted to become a doctor? It was the janitor who saved the life of a boy, and House witnessed it. He was "just a janitor" who also happened to be a doctor but was also an "Untouchable," so he could no longer be in that status. Plus Jen, this actually is a more difficult case too. Chai and Silja have followed exactly what the original case did, and they took awhile to get the specific diagnosis (they were hanging in "Some sort of meningitis that is unresponsive to typical treatment and got many "negative" tests). Actually, Silja and Chai - would either of you be opposed to running a "training case" of some sort where we could introduce people to the process of the game? That way we can have more players who can win more and present cases more. Also, I heard from vollower who had been with us a lot back in Old Country. She says that life has been hectic lately and she hasn't been able to join us but might if things can straighten out a bit more. ~~~~~ Chai: You still got the spinal fluid? arizona: Yeah. Chai: Good, then run viral cultures on it. Also check for pleocytosis. Repeat the cultures--maybe bacteria will show up this time. Just for funsies, check for mouth ulcers. arizona: Whoah! I'm still writing this. Chai: Also, get an ophthalmologist so we can check for signs of Vogt-Koyanagi-Harada syndrome; she may be in the meningoencephalitic stage. At this point, we have half a diagnosis. We just need to find underlying cause. arizona: I agree. But, the underlying cause will also tell us how to treat her. I checked with the nursing staff as well… House: Are you sure you want to use the same spinal fluid? I'd rather check to see if any values had changed. arizona: Chai, I'll rerun our LP from before, and check for those things. But I'll leave it up to you and Silja if you want to draw any new labs. House: I would. arizona: I think I'll just run a new LP. Jen: Don't mind me, I'm just cleaning, but that sounds like a good idea. arizona: I'm back with the labs. Viral cultures negative. Bacterial cultures did not take for us (also known as - it will give us the exact answer and I'd rather make you work for it). No mouth ulcers, Ophthalmology said there was nothing wrong with the eyes. House: What about the repeat LP? arizona: Mononuclear white cells have jumped to 900. House: Don't thank me. What bacterial infection causes a positive ANA and an increase in monocytes? And that doesn't always test positive by means of the traditional test. Which may or may not have already been run. arizona: So we look back over the long list of tests run earlier? House: Exactly. No, get Jack back. arizona: Also, Sasha is unresponsive to the acyclovir, but the corticosteroids have relieved some of the pressure - in the process of keeping the immune system from working as well. So, she's fluttering on the edge of consciousness now.

In the absence of splenomegaly, pharyngitis, rash or adenopathy? Oh, dear... *pst* do a monospot...

*moves to start cleaning the glass walls separating House's office from Diagnostics.* Have you guys tried doing a monospot? Because Silja might be on to something. So basically we're just presented with symptoms and have to try and diagnose. Don't we have to be friggen doctors to be able to do that, even in a game? Maybe I'll promote myself to intern next go around, or I'll just stay as the janitor.

So basically we're just presented with symptoms and have to try and diagnose. Don't we have to be friggen doctors to be able to do that, even in a game? Maybe I'll promote myself to intern next go around, or I'll just stay as the janitor. Yup (I'm a music teacher and CNA by training - Silja and Chai are actually in the medical field). You just look at the symptoms and practice your mad googling skills. So in this case - headache, stiff neck, fever = meningitis. Now, and this is where this case is difficult, we have to figure out which bacterial (yes, I know what the tests say) organism it is. So, we go over the gamut of lab tests we've already ordered to see which is borderline and questionable, and had two stars next to it earlier. Also, I like to look for other clues in there too Jen. ~~~ Silja: In the absence of splenomegaly, pharyngitis, rash or adenopathy? Oh, dear... *pst* do a monospot... Jen: I agree. the Doctor: Sure. *zips* House: Where's arizona? arizona: Evil nursing home!!! I had half a unit on my own for five hours! House: Go back to sleep. arizona: Okay the Doctor: *zips back* Monospot is negative. It looks like we'll need to amplify the bacteria's DNA for better identification. Especially since this bacteria may take about six weeks to culture, and even the TARDIS has her limits. House: If only there were at test for that… the Doctor: Aw, 1983, that was such a great year. I remember going back then, and just playing around with what's his face in his lab. He won the nobel prize ten years later for that work… House: Ahem! the Doctor: Right, the test! Especially since one of the tests earlier was borderline on being positive. Maybe we should look at that specific test again and see if there's a more sensitive test that works better, even though it's a lot more expensive. House: Why are you giving medical advice? the Doctor: I'm the Doctor. And I know the article arizonamyrie is using for this case. House: How convenient. Can you bring back Jack? the Doctor: Jack's busy.

The tuberculosis test! Tubercular meningitis could cause most of these symptoms. Confirm with a QFT-Gold test--it's much more sensitive. It's possible that her PPD was skewed by a BCG vaccine because she is from Russia, and that's why it's positive, but the borderline TB test is the closest thing to a lead we have. At least, a lead that will take under six weeks Arizona, what kind of music do you teach? I knew about your nursing, but not about the music thing. Very cool!

Chai, my formal training is in K-12 instrumental music with a jazz studies emphasis. Unfortunately, there are also no jobs in my field any more unless you've been a substitute teacher for over 10 years, and even then, the jobs are mostly 15% time. So, I'm going back to school for nursing, and eventually want to become a family nurse practitioner with a special interest in medical problems of musicians. I play flute, piano, and saxophone, as well as compose. I played in all the instrumental ensembles at my college, and even got to work with The Clayton Brothers, John Scofield, Bobby McFerrin, and a few others. As far as music jobs go, right now, I teach private lessons at a local music store (literally a job I walked right into - the phrase "I teach piccolo lessons - but they have to bring their own ear plugs" sealed the deal). Gigs were scarce until the last few weeks when I've been called often but had to decline due to my schedule. That, and I've injured all the tendons in both of my arms. Also, I had a very surreal experience at work tonight. I held up the foot of a man who had just passed away from a hemorrhaging pressure sore. It really didn't seem like it had happened. We knew he was in rough shape, and I hadn't really worked with him at all, but it was just - surreal. Like I saw it happening, but had distanced myself so much that I didn't really know what was happening. The thing that bothers me most is that I am fine. This is the sixth resident that passed away in my unit since I started eight weeks ago, and there are probably one or two more on their way. Chai, how far along are you in med school? I know you had recently done liver rounds, so I'm assuming either one of the last years or intern. ~~~ Chai: The tuberculosis test! Tubercular meningitis could cause most of these symptoms. Confirm with a QFT-Gold test--it's much more sensitive. It's possible that her PPD was skewed by a BCG vaccine because she is from Russia, and that's why it's positive, but the borderline TB test is the closest thing to a lead we have. At least, a lead that will take under six weeks arizona: I'll go check. You can play with Capt. Jack for awhile. Capt Jack: Hey there! Chai: *squees!* arizona: One case of Tubercular meningitis confirmed! From the article: The tuberculosis bacillus, once called "the captain of all these men of death," can be fiendishly elusive. It always enters through the lungs, but it doesn't always stay there. In about 15 percent of cases, the first signs of disease crop up elsewhere. And in half of those cases, chest X rays are normal. To get to the brain, the TB bacilli must evade the lungs' immune defenses and slip into the bloodstream. Once the bacteria reach the space beneath the outermost membranes of the brain, where the cerebrospinal fluid flows, they form clusters. On occasion, a cluster bursts, sending new bacilli through the brain's fluid-filled passages to establish new colonies. The process can smolder for months, causing inconstant, subtle symptoms doctors often miss. House: Chai, you have the pager. arizona: Congrats. And I highly recommend you read the article.

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