2. Case Scenario
Presenting complaints
A 65 year old Caucasian male was admitted acutely
complaining of generally feeling unwell with fever,
painful skin swellings over his arms and legs,
headache and epigastric pains.
3. Past History
He had a complex 4 years history when he presented
with intermittent fever and chills, arthralgia of large
joints, painful skin nodules of arms and legs, dry
cough, shortness of breath, redness of his right eye,
painful right testicle, anorexia and weight loss of two
months duration.
4. Past History
He denied oral or genital ulcers. Over the
ensuing two months he was extensively
investigated to define the underlying disease.
6. Investigations
Normal total white blood cell (WBC) count and
differential.
Rouleoux, oval macrocytes. Pseudo Pelger-
Huet cells and occasional myelocytes on film.
Platelet and reticulocyte counts were normal.
7. Liver function test:
Gamma-glutamyl transferase 172 (7–64iu/l),
Alkaline phosphatase 399(42–121iu/l), Albumin 16
(32–55 iu/l),
Bilirubin and alanine aminotransferase normal.
8. Chemistry
Urea 10.2 (3–6 mmol/l), creatinine137 (53–115
umol/l).
Normal sodium and potassium.
Immunoglobulin (IG) G level was raised
(polyclonal) 19.1(8–18gm/l).
Normal IgM, IgA and IgE levels.
9. Radiological tests
Chest X-ray: Bilateral patchy basal
consolidation and mild bilateral pleural
effusions which were confirmed on
computerized tomographic scans.
Ultrasound scan of scrotal sac showed
changes consistent with epididymo-orchitis.
CT scan of the abdomen: normal.
10. Serological tests
The following serological tests were done and
found to be negative: Hepatitis B & C screen, HIV
test, anti-nuclear antibodies, anti-DNA antibodies,
rheumatoid factor, anti-cytoplasmic antibodies,
anti-cardiolipin antibodies, Coomb's test, ASO titre,
cryoglobulins, Brucella serology, complement
levels, C1-esterase level.
11. Other tests
Other negative tests done for a possible
infective agent: Malaria film, Brucella culture,
Mantoux test, sputa for acid fast bacilli, leprosy
nasal smears, urine microscopy.
12. Skin biopsies
Two skin biopsies were taken:
Sample1: Summary of findings:
Picture of panniculitis with vasculitis.
Sample 2: Summary of findings:
Picture consistent with leucocytoclastic vasculitis.
14. Other biopsies
Found to be negative/normal were:
Bilateral temporal artery biopsies
Conjuctival biopsy
Liver biopsy
Bronchoscopy and bronchoscopic samples
Bone marrow aspirate/biopsy: Unsuccessful initial
attempt. Patient declined a repeat.
16. Use Bed-side Diagnosis
Schemes: PR, 3Rs, HD, ST
1. Pattern-recognition PR: Spot Diagnosis/
Syndromic
2. “Rules of Thumb”: Smart Heuristics
3. Rule-Out Worst Scenario ROWS
4. Red Flags (symptoms or signs of more serious
pathology-usually after diagnosis is made) etc
5. Hypothetico-deductive HD Strategies (from H&P)
6. Scoring Tools: Well’s, CAGE etc.
17. Hypothetico-deductive HD Strategies
Detailed history
Clues from all components of the
history
Comprehensive physical examination
May need to revert to investigations if
no diagnosis is clear.
18. Hypothetico-deductive HD Strategies
Qualifying Statements
Frugal Pre-test Probability Assessment: The AP Scheme
1. Absent Alternative: No alternative plausible bed-side Diagnosis:
Yes/No
2. Presence of Strong Risk factor for the condition: Yes/No
Interpretation:
High Probability (2 YES) or
Intermediate Probability(1 YES 1 NO) or
Low Probability (2 (both) NO)
19. Extras: Qualifying statements
Experienced clinicians often group the findings into
meaningful clusters: Qualifying Statements
Hypothetico-deductive Strategies (from H&P)Item Qualifying Statement
Time Frame Acute/Chronic e.g. Acute Onset
Body Site Anatomic Location e.g.
Abdominal pain, generalized
swelling, generalized itching etc.
Associated Discriminating
Symptoms
Painless Jaundice
One Organ -System/Multisystem Local versus Systemic disease
20. Extras: Qualifying statements
Experienced clinicians often group the findings into
meaningful clusters: Qualifying Statements
Hypothetico-deductive Strategies (from H&P)Item Qualifying Statement
Epidemiological Clues Race, Geography, Social Habits
etc.
Specific Laboratory, Radiologic,
histologic, Serologic Clue
Positive highly specific result etc.
Known Complication/Association Auto-immune Diseases etc.
22. Next Steps: Diagnostic Paths
1. Redo H & P
2. Read a list of Differential
Diagnosis in a textbook
3. 2nd
Opinion: Consult a Colleague
4. Present in a Clinical Meeting
5. PubMed Search: Literature
Review of similar clinical cases
6. Therapeutic trial