DISQUS

A Happy Hospitalist: http://thehappyhospitalist.blogspot.com/2008/07/differential-diagnosis.html

  • Anonymous · 1 year ago
    Multiple myeloma? Amyloidosis?
  • Nurse K · 1 year ago
    Anything to suggest physical abuse? Maybe she's denying traumatic injury because the injury is being caused by someone, like the kids' dad or an adult son. Sometimes people deny abuse w/obvious trauma because they think we'll come to the the conclusion of abuse on our own without them having to say it and risk further injury.

    My guess is that if the family says she falls, she's probably falling, but is afraid of being placed in a nursing home or something to that effect.

  • JunkMD · 1 year ago
    Possible differential:
    Hypothyroidism?
    Pertussis?
    Renal Failure?


  • yay · 1 year ago
    There's a picture that looks a lot like that in my clinical examination book (Talley & O'Connor).

    Hmmm... it says that with amyloidosis causing macroglossia, bilateral periorbital purpura following a proctoscopic examination is characteristic, albeit rare.

    Don't quite see how that fits into lying down or falling though :p



  • Frank Drackman · 1 year ago
    Saw that happen in an F-16 pilot who had pulled like 8Gs. Tell Grandma to ease up on the Stick.
  • ck · 1 year ago
    Periorbital purpura caused by laying down? About all I can think is some sort of slight venous laceration in the orbit/forehead area that is re-opened upon laying down (blood pools). Etiology of that is difficult though. Is she on anti-coagulants? Does she get the bruises anywhere else? Macroglossia (for the aforementioned amyloidosis)?

    Nurse K: "like the kids' dad or an adult son." Depending on which source you use, women are commonly the abusers (45-75%). Especially in cases of hard to confirm abuse -- usually because male-perpetrated abuse is much more obvious (i.e. a broken arm).

    *We had a nice chart for some class on the profile of abusers (child/domestic/elderly) that showed women ~70% of elder abusers. I can't find the paper they pulled this from though, just a quick google search pulls the above stats.



  • Nurse K · 1 year ago
    Huh, who knew. Anyway, you get the point. The chances of it being abuse or falls with a made-up story to go with it are much greater than some very obscure diagnosis.

    Here's a zebra case report for you, HH.

  • Bianca Castafiore · 1 year ago
    What would you expect to see in a head CT were the patient
    *falling or
    *being abused
    to the extent necessary for production of bilateral periorbital ecchymosis?
    Also, is there significance to the bilaterality?



  • The Happy Hospitalist · 1 year ago
    bianca. A basilar skull fracture gives you the "raccoon eyes which can look like that. It is always bilateral.

    Nurse K. Interesting. Thanks. Also, how do you create a link in these comments. I don't know what the HTML is to do that. Care to share?

    No macroglosia. No globulin gap (one of my 20 rules to look for). No renal failure. No cough. TSH normal.



  • igloodoc · 1 year ago
    Cavernous sinus thrombosis?

    Any nerve palsy?
    MRI/MRA show anything?


  • The Happy Hospitalist · 1 year ago
    No nerve palsy. No MRI done. Interesting thought though. What's the physiological explanation for raccoon eyes in a cavernous sinus thrombosis? I've never heard of the connection. I guess I'll look it up.
  • Teresa · 1 year ago
    Dr. Happy, the basic link html is as follows:

    < a href = "http://thehappyhospitalist.blogspot.com" >Happy's Place< / a >

    You will need to remove some of the spaces. Let's see if I can show the spaces that should be removed with a "-":

    <-a href-=-"http://thehappyhospitalist.blogspot.com"->Happy's Place<-/-a->

    Yick. That's a tad confusing. Probably a page with the syntax described is better.

    Or you can always right click this page, choose "view source" or something like that, search on "zebra" and you'll see the code for the link.

    Once you write up the comment with a link, be sure to use "preview" to make sure you got the html right.











  • The Happy Hospitalist · 1 year ago
    That was very helpful. Thank you very much!
  • igloodoc · 1 year ago
    I am probably over-reading the picture, but it looked like there was either an edema or cellulitis component with the ecchymosis.

    The one I saw (long ago) presented with the same kind of history, and ecchymosis with edema. It was a partial cavernous sinus thrombosis, and the swelling went away with position. I assumed that you CT facial bones to rule out an occult LeFort fracture or broken nose.

    I suggest a MRI/MRA if it is not getting better...



  • JunkMD · 1 year ago
    Happy,
    Do we have a diagnosis yet?
  • The Happy Hospitalist · 1 year ago
    I don't think we're going to find one