# Life is hard.



## Veneficus (Nov 6, 2010)

Scenario disclaimer.

The purpose of this scenario is to challenge your technical medical knowledge and present conditions that are definitely “outside” the box. I really like the way some scenarios were presented started from the EMS standpoint and moving towards the hospital, so I am going to steal that format. (Imitation being the best form of flattery) Everyone is encouraged to participate, but honestly this is directed to challenge the regulars on the site who have demonstrated medical knowledge well above the average. This case is real and the only details modified were to make it more friendly to the North American members.

There is no need to type out this is beyond the scope of EMS and you would just transport, I am already aware of that.

There is no need to say you would be nice to the patient and hold his hand. 

I will do my best to answer all questions as they arise. 

Now that we got that out of the way:
Your patient is a 33 year old male. He complains of shortness of breath on exertion and feeling like he is going to pass out when he gets up from sitting too fast.

You arrive on scene to a lower socio-economic class residence, The dwelling appears to be clean, however, in slight disrepair, worn curtains and furniture, unrepaired drywall cracks, etc. The tv is small around 20 inches, and there is no THX stereo system. (nobody here on welfare)

You find the patient surrounded by his family (mother, father, and sister all who seem very upset with him and not very sympathetic) in his room, sitting on the bed, looking nervous. He appears dressed in clean cloths, though old, and is clean and shaven with no dirt under his nails, and overweight.

Vital Signs:
HR: 106 (sinus tach with <8 PVCs/min, some couplets)
BP: 170/110
RR: 14 non labored. 
Temperature: 36.5
Spo2: 100% RA (normal waveform)
Capillary glucose: 80
A/B index is normal at 1.0. (not that I regularly do this on scene, but the lack of finding certainly complicates things)

Physical exam findings:

HEENT: Head and face are symmetrical with no deformities or enlarged lymph nodes. Face has a red hue to the skin suborbital extending about 5 cm to the lower part of the mandible and back to the ear. Sclera are white and have multiple small arteries evident.  Ears are free of serumen, and tympanic membranes intact, no signs of inflammation or infection. Nose is unremarkable. Inspection of the mouth yields >20 dental carries and widespread destruction of the teeth. There are signs of inflammation throughout the oral cavity , (redness and swelling) Pt. states he takes NSAIDS for pain as needed, but teeth are not bothering him now. Enlargement of the tonsils is noted. Face and neck have obvious fat deposits, but are otherwise normal with no enlargement of the thyroid or local lymphatics. Carotid pulses are present bilaterally with no bruits.

Thorax: Gross signs of central obesity, gynecomastia on front, suprascapular fatpad posterior. No body hair, axillary nodes unremarkable, proportional dimensions of the chest. Lung sounds are clear bilaterally, heart sounds have an easily audible Mitral and Tricuspid regurgitation with a very abnormal clicking sound (not medically described) with the mitral tone. Upon percussion of cardiac boarders, there appears gross enlargement of the myocardium. 

Abdomen: Is obese, soft, liver is extended 6cm past the costal margin, no splenomegaly evident, No caput medusa or other signs of poor circulation, diffuse purple striae (stretch marks) are noted circumferentially. Abdominal sounds are present. Genitals appear small, but there is no report of parasympathetic or sympathetic dysfunction upon questioning. Pubic hair is notably absent.

Upper extremities have lower level of obesity than central body, all pulses are present, musculature is atrophied but there is full range of motion without pain. Neuro is intact and redness on the skin similar to the face is noted distally. Body hair is absent

Lower extremities have bilateral pulses, neuro and range of motion normal, no pain, with +2 pitting edema and absent body hair.


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## Veneficus (Nov 6, 2010)

History of present illness:
Patient states over the last few days he has become increasingly short of breath when performing routine activities, made an appointment to see a GP which was to be tomorrow, Several times over the last 24 hours he has felt like he was going to pass out when standing up. He called the GP to tell him and was advised to call 911. (999, whatever you use)

Past medical history:

The patient has seen muliple GPs over the years for various medical complaints though rarely the same one twice due to inability to pay. No prior Dx of significance was made. He was counseled about his weight and diet back when he started to uncontrollably gain weight his senior year and was no longer able to participate on the wrestling team. The patient is also a recovering alcoholic and states he has been dry for 2 years to date with no relapses after his last MD visit he was told he would die of liver failure if he didn’t stop drinking.

Social history:
The patient lives at home with family, has not had steady employment, no longer drinks, never smoked, never used drugs and has frequents street ladies when he has spending money. (Has never had an STD test, and reliably denies having any signs or symptoms of one upon intense questioning.) The family is not supportive feeling he is too old to be at home, malingers from some “made up” sickness, and tolerates him because he is family. The patient performs various unskilled labor tasks when he is able, but has had no steady employment. The patient and family also state that he adheres to a strict weight control diet and while not able to regularly exercise, and doesn’t lose weight, he has maintained a constant weight since no longer consuming alcohol.

What do you think is wrong with this patient? Is he stable or unstable? What would you do for him? If you had a treat and release or refusal of transport protocol would you take him to the hospital, make him find his own way, or leave him? What is his most urgent concern? Does he have multiple sicknesses creating his problems, or one sickness manifesting various signs? What tests would you want to see when he got to the hospital? Would you admit him? What service would you admit him to?

(Think hard, this is likely to be a once in a lifetime case)


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## gicts (Nov 6, 2010)

Questions: What is his race? Could sickle cell anemia be a part of his condition?
Does the family exhibit any of the symptoms? Could it be an environmental issue?
What does his diet consist of?

My general observation of his symptoms would lead be to believe he is anemic or dehydrated. Because of his promiscuity I wonder about HIV, and because of his poor oral hygiene I  wonder about oral cancer.


From me he would be getting a cardiac work up and blood glucose check ( I see you listed those  ) and if I feel like playing on-scene, an orthostatic set of blood pressures. For the most part I am comfortable calling him stable and transporting. I am curious if there is a cardiac disturbance that arises with exertion, and his pitting edema at his age concerns me :wacko: .

I would also consider a thyroid disorder or something like Addison's disease due to his weight gain and flushed face.


The lack of pubic hair has bee thrown for a loop. Your hints have me feeling I am missing something and I'm interested in seeing how everyone else responds. He sounds like many of the patients I pick up.


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## Veneficus (Nov 6, 2010)

gicts said:


> Questions: What is his race? Could sickle cell anemia be a part of his condition?



He is a white male of Central European ancestory.



gicts said:


> Does the family exhibit any of the symptoms? Could it be an environmental issue?



No, the family has no significant medical history and all are very fit.




gicts said:


> My general observation of his symptoms would lead be to believe he is anemic or dehydrated. Because of his promiscuity I wonder about HIV, and because of his poor oral hygiene I  wonder about oral cancer.



I will post the lab values after a few more responses or sunday night. He is not dehydrated as evidenced from mucous membranes and history of oral intake. But he has no communicable disease and nor overt sign of neoplasm in the head or neck. 



gicts said:


> and if I feel like playing on-scene, an orthostatic set of blood pressures. For the most part I am comfortable calling him stable and transporting. I am curious if there is a cardiac disturbance that arises with exertion :wacko: .



On scene orthostatics produce near syncopal episodes with unsustained runs of VT and a drop in BP to 90/60




gicts said:


> The lack of pubic hair has bee thrown for a loop. I'm interested in seeing how everyone else responds.



It is a very interesting finding considering that hirsutism is a regular finding in Cushing's, he has other signs but the absence of hair is strange.


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## Veneficus (Nov 6, 2010)

*have to add*



Veneficus said:


> On scene orthostatics produce near syncopal episodes with unsustained runs of VT and a drop in BP to 90/60




Which spontaneously resolve after a few minutes


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## EMSLaw (Nov 6, 2010)

The lack of body hair (alopecia universalis?  Everything sounds more profound in Latin.) combined with sudden and unexplained weight gain lead me to suspect a thyroid dysfunction.  Hypothyroidism could account for both, as well as his daytime fatigue, if that is what it is.  I send the patient for a battery of lab tests in which they draw a pint of blood into little colored tubes, then refer for an endocrinology consult to rule out.  

Speaking of his history of oral intake, though... Polyuria, nocturia, enuresis?  Polydipsia?

I might not be one of those medical knowledge above average types, so...  Hopefully I'm not making a fool of myself.


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## Veneficus (Nov 6, 2010)

EMSLaw said:


> The lack of body hair (alopecia universalis?  Everything sounds more profound in Latin.) combined with sudden and unexplained weight gain lead me to suspect a thyroid dysfunction.  Hypothyroidism could account for both, as well as his daytime fatigue, if that is what it is.  I send the patient for a battery of lab tests in which they draw a pint of blood into little colored tubes, then refer for an endocrinology consult to rule out.



Endocrine is a great place to start.   



EMSLaw said:


> Speaking of his history of oral intake, though... Polyuria, nocturia, enuresis?  Polydipsia?



No and never.



EMSLaw said:


> I might not be one of those medical knowledge above average types, so...  Hopefully I'm not making a fool of myself.



Nonsense, above average medical type starts when your answer is more complex than "I would put him on 15L NRB, start a line, hook him up to a cardiac monitor and drive very fast to the hospital following my protocol for such a case."

(If you have a protocol for this condition, your service sees some very messed up people too regularly)


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## Aidey (Nov 6, 2010)

What is A/B index? 
Has he had the routine inoculations? MMR? 

Something is both irritating his heart and preventing it from working properly, my suspicion is infection secondary to the multiple caries, but he is also presenting as if he has a significant endocrine disorder. 

With his lack of consistent primary care, and general overall poor health it is possible there are multiple things going on, but Occam's razor and all...


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## Veneficus (Nov 6, 2010)

Aidey said:


> What is A/B index?



Ankle/brachial index, can give a clue about vascular occlusions. A normal finding indicates that no significant vascular occlusion is detected.



Aidey said:


> Has he had the routine inoculations? MMR?



He has had all relavent innoclations. 



Aidey said:


> Something is both irritating his heart and preventing it from working properly, my suspicion is infection secondary to the multiple caries, but he is also presenting as if he has a significant endocrine disorder.


 
He does seem to have a plethora of cardiac issues. It looks to me like you are thinking it is multiple conditions simultaneously complicating his clinical picture?



Aidey said:


> With his lack of consistent primary care, and general overall poor health it is possible there are multiple things going on, but Occam's razor and all...



There is nothing simple about this one. The labs, which I will post Sunday eve, confound the picture even more. Sorry.

One of the reasons I wanted to split this scenario up a bit, is because it demonstrates very well why providers should always treat the patient and not the numbers. It was his physical findings that ultimately led to the proper dx.


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## Aidey (Nov 6, 2010)

Veneficus said:


> Ankle/brachial index, can give a clue about vascular occlusions. A normal finding indicates that no significant vascular occlusion is detected.
> 
> *Ok thanks. *
> 
> ...



10char


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## Veneficus (Nov 6, 2010)

Treatment options are ok, they could obviously help the pt, make it worse or make no difference depending.

If I am not mistaken, endocarditis is the cardiac infection you are looking for.


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## EMSLaw (Nov 6, 2010)

Well, since I'm playing doctor... What do his hands look like?  Any blunting or rounding of the metacarpals? 

Hrm...  Having been advised that I'm possibly in a right church-wrong pew situation, and having done a little additional light reading (ha!), I'm starting to think maybe the small genital size also is more than just coincidance, which could lead to the conclusion that the problem is with the hypothalmus.  

Adiposogenital dystrophy?  Possibly secondary to tumor on the hypothalmus? Let me whip out my portable radiology suite while I'm getting that endocrine consult.  I had also thought diabetes insipidus when I first started working this through, but I'm not entirely sure.  

Of course, you're right from an EMS perspective that there's nothing we can do except transport.  My gut feeling from what you've outlined is there's something wrong that needs to be seen to.  If it's CA or DI, then it is life threatening, even if not in a "gonna die right this second" way.


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## Aidey (Nov 6, 2010)

Yes endocarditis! That was going to bug the heck out of me.

What does his EKG look like when he is in sinus?


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## abckidsmom (Nov 6, 2010)

How long was he using steroids when he was on the wrestling team?


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## gicts (Nov 6, 2010)

For what it is worth, when researching mitral valve prolapse, I learned those patients commonly have a lower body mass index than the typical population. 

Yet another thought out the window 

Carry on B)


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## Aidey (Nov 6, 2010)

I wondered about sterioid use too, but assuming he only used in high school it would have been 15 years or ago, and I wouldn't expect it to just show up now. Unless the endocrine problem has been going on undiagnosed for years. Can the pt remember how long he has been hairless?


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## mycrofft (Nov 6, 2010)

*When he gets faint...*

Tinnitus? Visual disturbances? Vertigo?


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## abckidsmom (Nov 6, 2010)

Aidey said:


> I wondered about sterioid use too, but assuming he only used in high school it would have been 15 years or ago, and I wouldn't expect it to just show up now. Unless the endocrine problem has been going on undiagnosed for years. Can the pt remember how long he has been hairless?




I wonder if steroid use or chronic steroid overdose during late adolescence caused Cushing's disease...maybe with gradual onset, or gradual worsening.  I think he's visiting the ladies of the night because they're the only chicks he can get alone with and probably not consummating his relationships with them.  

Currently, I'd call him pretty unstable.  He's potentially full of clot with the increased abdominal pressure and huge heart, he's probably relatively hypoglycemic (can't imagine that 80 is anything like his normal BGL), and he's near-syncopal.  

I'm feeling confident enough to take a stab at the answer:



> What do you think is wrong with this patient? Is he stable or unstable? What would you do for him? If you had a treat and release or refusal of transport protocol would you take him to the hospital, make him find his own way, or leave him? What is his most urgent concern? Does he have multiple sicknesses creating his problems, or one sickness manifesting various signs? What tests would you want to see when he got to the hospital? Would you admit him? What service would you admit him to?



I'm not a fan of treat and release in general, and especially not in people who have documented potentially lethal dysrhythmias.  I'm going to take this guy to the ER.  I would think that his most urgent concern is his metabolic disarray:  I'm going to guess that his electrolytes are pretty out there, and one of the first steps is going to be replacing 'lytes as needed.  After that I'd imagine that his ectopy would settle down, but would probably need an antidysrhythmic to assist with that.

He has systemic, severe symptoms of Cushing's disease.  I have no idea how his treatment would go past the initial stabilization, but I'd expect him to be admitted to the MICU and followed by the medicine service.


This is me, going way out on a limb.


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## 46Young (Nov 6, 2010)

Aidey said:


> Yes endocarditis! That was going to bug the heck out of me.
> 
> What does his EKG look like when he is in sinus?



Beat me to it! I was just reviewing the S/Sx of both pericarditis and endocarditis (hypertrophic cardiomyopathy is a risk factor). I was basing that on the suspicion of the dental infections spreading elsewhere.

As far as a txp decision, orthostatic changes w/ runs of V-Tach would definitely warrant txp to an ED. I'd work him in the house as far as diagnostics and prophylactics are concerned. I'd hate to be moving him when he goes into sustained V-Tach or worse, and not have a line, at the least. I'd also have the pads on him just in case. I'd also have my arrest drugs and advanced airway equipment at the ready, etc.

Can't wait to see his labs! Did he get an echo?


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## 46Young (Nov 6, 2010)

abckidsmom said:


> I wonder if steroid use or chronic steroid overdose during late adolescence caused Cushing's disease...maybe with gradual onset, or gradual worsening.  I think he's visiting the ladies of the night because they're the only chicks he can get alone with and probably not consummating his relationships with them.
> 
> Currently, I'd call him pretty unstable.  He's potentially full of clot with the increased abdominal pressure and huge heart, he's probably relatively hypoglycemic (can't imagine that 80 is anything like his normal BGL), and he's near-syncopal.
> 
> ...



Cushing's sounds like a good place to start. Many of the signs match up. The fact that his whole family is fit and he's the only one that's not increases my index of suspicion to that end. He may also have LVH from the steroid use you mentioned.


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## Aidey (Nov 7, 2010)

I would hesitate to call it Cushing's Disorder since that is caused by a specific thing, and we have no idea what is causing it yet. He definitely has some sort of hypogonadism going on.


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## Veneficus (Nov 7, 2010)

A trip to the ED, and beyond:

ED tests included: 

a head and abd CT. 3 micro infacts in the head scan

abd was normal

cxr showed cardiomegaly

CHM 12:


comprehensive metabolic

glucose: 130mg/DL
calcium 10 mg/dl
albumin 4.2gm/dl
protein 6.4
sodium 184 meq//L
potassium 4.3
co2 32/ meq/l
chrolride 116 Meq/l
BUN 14mg/dl
creatine .6mg/dl
ALP 211 u/L
ALT 66 u/l
AST 56 u/l
Billirubin direct .9
total: 1.9

cardiac markers:

trop I:ng/ml .11
trop T .22
myoglob: 101
ck: u/l176
ck mb: 7

Heme:

RBC 5.6 m/ul
WBC 12 K/mm3
HGb 17 
hct 50%

ABG:

PH 7.33
paco2 40
pao2 80
hc03 98%
BE -1
hco3 22 meq/l

*Pt was admitted straight to cardio *(where i first saw him) with the following significant findings:

Cardiac echos (transesoph and transthoracic)

Showed dialated cardiomyopathy with tricuspid, mitral regurg, and Septal Anterior Motion. (SAM)

 (I don't remember the dimentions or % regurg, they were very large)

Ejection Fraction calculated: 45%

Pt able to walk 322 meters without difficulty.

*Endocrine consult:*
cortisol:
morning: 30mcg/dl
afternoon: 13 mcg/dl

dexameth test: Normal ACTH
basline cortisol

Answers to your questions:

_Well, since I'm playing doctor... What do his hands look like? Any blunting or rounding of the metacarpals?_

Not to any appreciable degree

_Adiposogenital dystrophy? Possibly secondary to tumor on the hypothalmus?_

Abnormal head CT findings detailed, no AD.

_Let me whip out my portable radiology suite while I'm getting that endocrine consult._

Endocrine consulted, but it took a few days to work this out.

_I had also thought diabetes insipidus when I first started working this through, but I'm not entirely sure_

Simply, no.

_What does his EKG look like when he is in sinus?_

Is there a specific detail past what I already mentioned you are looking for? I am not sure what you are asking.

_How long was he using steroids when he was on the wrestling team?_

patient reliably denies.

_Can the pt remember how long he has been hairless_

always

_Tinnitus? Visual disturbances? Vertigo?_

Not reported

_I think he's visiting the ladies of the night because they're the only chicks he can get alone with and probably not consummating his relationships with them._

Sexual function reported as normal in physical findings. Pt. was very reliable in all interviews.

Any further qestions or thoughts welcomed final DX tomorrow night.


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## Aidey (Nov 7, 2010)

Were any hormone levels done? 

Am I correct in thinking that you meant 3 micro _infarcts_? 

Well, that bloody well doesn't help. Outside of the heme values there are only about 5 normal values.


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## Veneficus (Nov 7, 2010)

Aidey said:


> Were any hormone levels done?
> 
> Am I correct in thinking that you meant 3 micro _infarcts_?
> 
> Well, that bloody well doesn't help. Outside of the heme values there are only about 5 normal values.



cortisol levels were normal, aldosterone levels grossly elevated, and adrogen levels depressed. Sorry typed in so many lab values I missed them.

Yes, 3 micro infarcts, I still cannot type or spell

and I did mention that the lab values just complicated the matter.


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## FrostbiteMedic (Nov 7, 2010)

Me thinks that I am going to have to leave this one to the more learned of my esteemed collegues on this site....or else I need to call Dr. House....


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## Aidey (Nov 7, 2010)

Where were the micro infarcts?

So, just to make sure I've got this right, he has never had body hair, but he is able to get an errection and ejaculate? You said genital size is small, is is just small or are we in micropenis territory? (Yes, that is the medical term before anyone asks)

How is his voice pitch? Can he smell? Any vision issues? Did they do a d-dimer or VQ?


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## Aidey (Nov 8, 2010)

Ok, after about 8 hours of research I think I've got everything covered (very slow night @ work).

I was able to account for all the signs and symptoms with 3 disorders.

1. Endocarditis secondary to dental caries
That accounts for the caries, swollen tonsils, dilated cardiomyopathy, elevated cardiac enzymes, slightly elevated white count, and the micro infarcts (clots from broken off bacteria colonies). 

2. Past alcoholism
Accounts for the LFTs, low protein and albumin, edema and high calcium.

It also explains the very strange endocrine results. Cortisol binds to protein in the blood, so hypoprotienemia can cause false negatives when testing for elevated cortisol. Because there is no protein for the cortisol to bind to, even if the cortisol is really there.

3. Congenital adrenal hyperplasia
I'm not sure what type, but it accounts for the hyperaldosteronism and the low androgen. I am assuming the cortisol is high, and the low protein caused a false result. 

So this covers those abnormal labs, the Cushing's like symptoms, the high glucose ( I assumed fasting labs), the high sodium, the HTN, the lack off body hair, the smaller penis and testes (that still work) and the gynomastica.



So, am I in the ballpark? The staium? The right sport? lol


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## EMSLaw (Nov 8, 2010)

*sighs*  On House, this is never the answer, but it seems to match many of the physical findings (as one would expect it to)...  So...

What about lupus?

I'm also curious to know whether I've been in the right ballpark, or even the right state, at any time.


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## Veneficus (Nov 8, 2010)

*Strong work to all those brave enough to have a go.*

Survey says:

Ok, maybe not the survey, but the experts (aka the senior staff docs here) say...

All of his pathology is likely secondary to Cushing's Syndrome with a very rare (though not unheard of) mechanism.

The stipulated mechanism based on the outlandish lab values is there is some defect in cellular cortisol metabolism which increases its duration of action.

Additional newly synthesized cortisol is shunted to mineralcorticoid (aka aldosterone) Making the glucocorticoid level normal and still developing clinical signs of cushings.

The initial symptoms appearing during his teenage years went either undx or misdx, leading to severe depression, concurrent alcoholism and liver failure.

The depression was probably also not helped by reduced level of sexual characteristics though still functional. 

Since the spotty medical care did not come up with a dx, the family attributed it to laziness, further degrading the social support mechanisms. 

Long term un dx or uncontrolled HTN from the aldosterone led to the dilated cardiomyopathy, with the SAM reducing the ejection fraction and subsequent arrhythmia and relief upon sitting/squatting. 

The pt was discharged today with largely supportive treatment and a rather grim prognosis. 

He was disqualified for heart transplant due to preexisting pulmonary HTN.

A pacemaker/defibrillator was implanted mainly for cardiac supportive therapy. 

Annular banding of the valves via angio or surgery was not attempted. Septal ablation was not attempted.

The Pt. got his teeth pulled and fitted for dentures.

Pharmacological hormonal and blood pressure control was initiated.

Antidepressant meds and psych follow up.

Family seems very remorseful and will probably be a little more tolerant and I even dare say sympathetic.

*Bottom line:*
If it looks like a duck and quacks like a duck, it's a duck no matter what the lab numbers are.

_No it was not lupus. Sorry._


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## Aidey (Nov 8, 2010)

Well, I was at least in the ballpark.

I thought my explanation of the false normalish cortisol levels was genius though


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## EMSLaw (Nov 8, 2010)

A very interesting case.  I was in way over my head.


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## Veneficus (Nov 8, 2010)

EMSLaw said:


> A very interesting case.  I was in way over my head.



Those are my favorite kind actually. 

This guy was in the hospital for 21 days while all of this played out. I would say you and Aidey did quite well for less than 72 hours.


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## MrBrown (Nov 8, 2010)

Brown was going to say cardiomyopathy or something cardiac; ie dialated myocardium, regurg, syncope etc

Now, orange "DOCTOR" jumpsuits for all!


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## 46Young (Nov 8, 2010)

MrBrown said:


> Brown was going to say cardiomyopathy or something cardiac; ie dialated myocardium, regurg, syncope etc
> 
> Now, orange "DOCTOR" jumpsuits for all!



Same here. I was thinking endocarditis secondary to the dental caries, and some sort of endocrine disorder that I couldn't quite figure out. Interesting case indeed.

Vene, keep them coming! We've all had those pts that we really had no idea what was going on. It's nice to get the full story. The best we can often get is a few differentials from the Attending if they're not too busy. In my experience, hospitals don't generally give EMS any pt info. We are usually limited to the ED staff on that particular day.


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## Aidey (Nov 9, 2010)

I was proud I was able to account for all of the signs/symptoms, even if I wasnt right.


What was causing the hypoproteinemia and elevated LFTs? Was that part of the endocrine issue or incidental?


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## EMSLaw (Nov 9, 2010)

Veneficus said:


> _No it was not lupus. Sorry._



Poor lupus.  Always the bridesmaid, never the bride.  

I suppose, having now re-read this thread with the answer in mind, that the fat pad to the upper back is the "hump back" of Cushing's that I should have recognized.


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## Veneficus (Nov 9, 2010)

EMSLaw said:


> Poor lupus.  Always the bridesmaid, never the bride..



It is usually the bride.

SLE has a predominance in females. (like most autoimmune disorders)


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## Aidey (Nov 9, 2010)

Oh, and where did the micro infarcts come from?


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