A case with No diagnosis .. discussion

[dr_amro]

السلامـ عليكمـ


Hi Tebgate doctors ,
we want to talk for some time about that case


please read carefuly
and we will try to think about the diagnosis


that wase acase i found it on a foreign site on the words of agirl


she was saying ....




I am a 23 year old women. On my 21st birthday I had the flu and possible strep throat. The months that followed included me constantly feeling sick (very fatigue) and having anywhere from about 4 to 25 blackouts a day, lasting up to 10 seconds, but not causing me to completely faint.





Since then, I have gone to numerous doctors, each giving lots of different tests and they still have not found a true cause for this problem. Two different tilt table tests have determined that my blood pressure drops dramaticly (103/64 to about 60/40) when I change positions and my heartrate speeds up and then drops very low (from 94 up to 150 and down to 60).


My life is no longer like that of normal girls in thier tweenties. I have to be careful standing up, I have little energy and sometimes have days where I can hardly get out of bed, and I have other strange side effects. I do want to mention that I am not depressed, and my fatigue is not related to my mood.


But, to fill you in on some of my other symptoms, my heart will race (pound) for no apparent reason (I could be laying down), I don't sleep well, I sometimes have uncontrolable shaky hands, commonly have a low grade fever, occasional problems swallowing and sore throat, occasional hot flashes, usually at night, extreme sweating, and problems with noise, light, and touch (could be related to migraines, but happens more often, with out the pain of the headache.)


The doctors have put me on Beta blockers, but I had breathing problems, steriods which made no difference, and proamatine (midodrine) which caused TOO many side effects. I have tried support stockings, drinking lots of water, and increasing my salt intake, with no luck. They have checked me for seizures, different diseases, inner ear problems, etc. They don't know what the cause is.


If it were just the blackouts, I could live, but all of the other problems make it very hard for me to live a normal life.


Please, if you have any suggestions as to what the cause of this may be, I would greatly appreciate a response. I personally wonder if all of this is caused by chronic fatigue syndrome, but I understand that this is still not considered a disease by many doctors, and I have heard from some that low blood presure is not a side effect of chronic fatigue( others say differently.)


Thank you for your help,


Casey





Hi again

that was the complaint from her own words


here I decided to rewrite that case to find a diagnosis


try to diagnose and give Ur proving items



waiting for Ur discussion


thx alot

[Dr.sabry]

وعليكم السلام

Good topic doctor

I think, diagnosis may be S.L.E

because SLE is dse of multisystem affection

to be sure,she can do some investigation as:
ANA
Urine analysis
CBC
Chest Xray

what's ur opinion?

[dr_amro]

welcome dr sabry
am with u that there may be for the first instance a some sort of multiorgan affection

but I think that all the case have one organ affection which is CVS
with other all are like side symptoms or constitutional
like the fatigue , fever ,headach
also report the age and psychicatric symptomes may be noticed

also and although the case seems to be like ur diagnosis by some symptoms

but I think SLE must have some criteria
the american association put 11 must criteria for the diagnosis of SLE
among them and it's very important is :
malar flush ( not present here )
artheritis ... also not here
kidney affection not present

but am with u in the wanted investigations

so now we have one DD which is SLE


thanks doctor
waiting for ur repass

and waiting for other openions and more discussion

[dr_amro]

where r u all ؟؟؟

[MaRiAm AnA]

I will try:emem:

but 1st why doctors don't give antibiotic for sore throat

may be bacteremia occur

:what!:

just trial

thaks dr/amro for this case:bravo:

[dr_amro]

ok

good try dr mariam

but ..

you supposed that there is a bacteria that cause the sorethroat
however
that sorethroat may be functional
for example myalgia in the palatal or pharyngeal muscles
or even weakness in the pharyngeal or oseophageal muscles presented as dysphagia but symptomatized by patient words as sorethroat

but ok
do a swab
and culture - sensitivity tests

what's ur opinion dr mariam ؟

[MaRiAm AnA]

yes

sore throat may be due to another cause rather than bacteria

and I am with u in do invest. for be sure

[dr_amro]

ok
dr mariam also i noticed some thing now that is against presence of bacteria
it's that she complains low grade fever
i think in bacterial infection there is mostly high fever


ok


let's discuss some items

now we are upon a case of a 23 years old female
that;s is very important
complaining of fatigue
with table tilt test positive i.e orthostatic hypotension
associated along with some sort of heart rate disturbances which is rapid increase in HR followed by rapid slowing down to less than normal
also with daily 3 to 5 blackouts with no complete fainting

add to that

the presence of sorethroat , dysphagia m tremors , headache , sweating , disturbances of senses

add to that also the past history of taking Beta blockers

all of that in my thought leads me to diagnose primarily the case as Chronic Fatigue syndrome

which may be caused by anaemia

the diagnosis is clinically
and by exclusion of other related diseases

may be heart disease
may be CNS dis
may be also strong DD ... hypothyrodism

so

if iam her doctor
i will ask her for doing
CBC
Thyroid functions
Heart Echo

what's ur opinions ؟؟؟؟

[dr_daadoaa]

we cannot exclude renal affection before urine analysis at least

&not all cases of sle have malar flush

photosensitivity is wih sle

but may i add othsr dd for this case

(polyneuropathy )

mainly autonomic , motor&to lesser extent sensory



as headache sweeting postural hypotention

can be considered autonomic neuropathy


while dysphagia can be considered
motor neuropathy

so it may be acase of pn for dd

[dr_amro]

ok
am with u dr daadoaa in all of ur words

but

if we try to enumerate a DD
we will find too many diseases

and if we will ask the patient to do investigation we will burden him so much

so try in your primary diagnosis to enclose ur words in three or four most likly diagnosis

but am with u if you r answering a Q in an exam

so and here

in the patient full history there is no renal symptoms
and the renal affection and relation with that other symptoms is weak
so exclude it

in another side
the malar flush and the SLE
of course it isn't a sure sign and i didn't say that
i say that there is critiria which must at least 11 of it present to say that the case is SLE

note that saying SLE to a femal patient in her 23 years age is not an easy decision
it make very bad depression which may disease her more than the SLE itself


Ammmm !!!

but i agree with u totally in ur PN diagnosis
but note that there is no sensory manifestation told by the patient

but may be


nice discussion doctor

thx alot

[salammasri]

I think this patient have problem in her alpha adrenrgic receptor and this is cosistent with her frequent black out her blood pressure drops and the rise in her heart rate


and it also cosistent with the other complaints





my heart will race (pound) for no apparent reason (I could be laying down), I don't sleep well, I sometimes have uncontrolable shaky hands, extreme sweating, and problems with noise, light, and touch (could be related to migraines, but happens more often, with

as it is due to over sympathatic activity
on the beta receptors


and this part of complaint is away to asome degree with my sugesstion



commonly have a low grade fever, occasional problems swallowing and sore throat, occasional hot flashes, usually at night,





at it may simply due her stress that caused some sort of immune deiciency



This diagnosis I think is so away from the clinical life
but i put in mind that many doctors examined her asked for investigations that could easly exclude SLE or P/n or ranal disease

[dr_amro]

very good particepation dr salam

:g :g

[sayed saad]

think about hyper thyroidism
1st of all t3 &t4 &tsh

[drmesleih]

i think you must rule out myocarditis or cardiomyopathy

[chalenger46]

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