Mr. Gordon Eames is a 23-year-old male who seeks care in the University of Louisville ER for the second time that week. He was discharged 14 days ago from an inpatient drug and alcohol treatment center and felt well until 10 days ago, when he started having fever, chills, coughing, muscle and joint pain. He last injected heroin 12 days ago.
He also complains that he keeps having “sweating spells” and that he has noticed a red rash and some swelling of the joints that are painful. His ankles were the first joints to hurt, but now his knees, hands, and elbows also hurt.
He saw the nurse practitioner in the urgent care section of the ER 2 days ago and some blood work, an ultrasound of his heart, an HIV test, and a chest xray were done. He was told his tests were normal and that he had a viral illness and to go home and take fluids, ibuprofen, and rest. He has returned because now the pain is getting so bad he can’t even walk and is having trouble feeding and dressing himself, and he has an itchy new rash that is driving him crazy. His only medications are the ibuprofen and the methadone.
He denies headaches, sore throat, runny nose, facial pain, weight loss, changes in urination or bowel movements, or changes in his hearing or vision.
He has a history of his hands turning colors and losing blood flow when exposed to cold, migraines, and has had surgery on his left arm for an abscess. He also has asthma and takes albuterol when he has a cough or cold. He has been on other medicines before for asthma but that’s all he takes right now. He has repeatedly enrolled in drug and alcohol inpatient and outpatient treatment programs, and was started on methadone replacement therapy at a methadone clinic 4 days prior to this ER visit.
He lives with his girlfriend and the inpatient drug rehabilitation therapy was court-mandated after he was arrested for public intoxication and served 7 days in jail. He has been imprisoned before for 2 years for selling pills illegally as well as on possession charges for heroin. He has only had sex with women outside of prison although he did have consensual oral sex twice with another inmate while in prison, and estimates 15 lifetime partners. He has inconsistently used barrier protection when having sex. He has smoked cigarettes since the age of 13 and continues to smoke a pack a day.
His sister has lupus, diabetes is “all over” his mother’s family, and his dad had a heart attack in his 30’s and died in his 50’s.
Triage vitals: T 99.7, HR 103, BP 132/66, RR 30, SpO2 97%.
Gen: disheveled, appears uncomfortable, conversant
HEENT: injected conjunctivae bilaterally, dental caries prominent, oropharynx clear, TM’s clear, Neck full passive range of motion
Chest: Mild wheezing bilaterally, mild supraclavicular retractions. No murmurs, regular rate
Abdominal: liver edge palpable 3 cm below costal margin and tender to palpation. Spleen not palpable. Bowel sounds present.
GU/rectal: no penile lesions or discharge, no rectal lesions or tenderness on examination
Musculoskeletal: joints of ankles, knees, hands, and elbows diffusely swollen and warm, with effusions seen in the wrists and knees. Pain severe with any active motion of knees or elbows; passive range of motion is normal. Tenderness of the thighs and calves. Exam for strength limited by pain but no deficit suspected, deep tendon reflexes intact at elbow, knee, and ankle. Normal gait.
Skin: raised round erythematous lesions with central clearing over extremities, lower face, and chest.
|WBC: 11000||AST 95 (10-45)||Electrolyte panel: normal, including calcium, phosphorous, and magnesium|
|ALT 115 (10-40)||RPR: negative|
|Hgb: 13.1 (13-16)||Bilirubin: 1.8 (0-1.5)||Urinalysis: normal|
|Platelets: 286,000||Serum tox screen: methadone +||Blood culture drawn|
|ESR: 15 (<20)||Urine tox screen: opiate +||Antinuclear Ab panel, Hepatitis panel and HIV labs drawn|
Mr. Eames is admitted to the hospital and treated with oxycodone and acetaminophen for pain while the possibility of treatment for his problem is evaluated by various specialties. He complains for “feeling awful” every day of his hospitalization and expresses the wish to be referred again for drug treatment so he can stay out of jail and try to make his relationship with his girlfriend work, asking if there is anything more effective than the inpatient withdrawal and counseling 12-step-based treatments he has tried so far. He knows that IV drugs are a major risk factor for HIV and says he is terrified if he does not stop using he will get HIV, which he knows isn’t curable. He is also worried about the methadone treatment center because it’s expensive, he doesn’t like the clientele, and he doesn’t feel like it has helped him the 2 previous times he tried it.