“Medicine is learned by the bedside and not in the classroom” (Sir William Osler 1849-1919)
Being aware of medical knowledge and facts is not useful unless a doctor has the ability to extract the accurate information from a sick person about his or her illness, as a second step data synthesizing should be obtain correctly. Taking a careful medical history should precede both examination and treatment.
To achieve the correct diagnosis of any disease, being able to complete medical history play an essential role. The history begins in detail with the presenting problems by taking the symptoms that were described by the patient. “It is particularly important to ascertain the temporal course of the illness, as this may give an important information about the underlying aetiology”. Go over the past history of the head or spinal injuries and any previous operations is an important to achieve the right diagnosis. Medications also could be the cause of certain neurological or apparently neurological syndromes. Therefore, inquiring about previous and current medications should not be ignored. (Clinical Examination, 7th)
Background and History
Mr. S “patient privacy” is a 25-year old Saudi male, and his hometown is Najran. Moved to Al Khobar since the first months of his life. Single and recently graduated from united states with bachelor’s degree of chemical engineering. Resigned from the Saudi Petrochemical Company as a result of declining his health condition. Living with his family which consist of six members, parents, sister and two brothers with overall health.
· Outline of History and Condition
Mr.S diagnosed with behcet disease 7 years back when he presented to New England Retina Associates Hospital in US with eye symptoms and gradual vision weakness secondary to pan uveitis as well as multiple follicular lesion in the skin, these symptoms consider as the reason of why he decide to visit the doctor, as the initial treatment he started on immunosuppressives.
I was in the hospital on the day when the patient presented there and shortly after I get the permission as well as going through the medical history, I asked him about his condition for the last few months, he stated that the last 6 months prior to his current presentation. skin lesions “boil like”started to appear in his in his axilla as well as the development of the genital ulcers with discharge
It dawned to me also that Mr.S also get a course of humira for the last 6 years and he was in a good condition until few months back when he finished the last dose of humira and has been denied from the treatment . As a result he stayed for 3-4 months without treatment. Symptoms starts to manifest back, In fact it start before stopping humira but increased when the treatment stopped.
Few days later and after tha patient have done his follow up, the symptoms had worsening more and more, Mr S start feel he was unsteady to the point of that he cannot stand by himself with history of falling down due to lack of balance. He went back to the emergency room then referred by them to the Department of Neurology, neurologist estimate his condition and suggest that the patient should be admitted to the hospital. To get a sufficient information about the case, I went back to the hospital and had a meeting with the patient and the doctor who was in charge at that time. It dawned on me that Mr.S was admitted to the medical ward as Neuro Bechet syndrome (NBS). Tha patient also was checked by the Ophthalmology who confirmed the absence of active uveitis and the presence of scarring only in the right retina.
Following with Mr.S condition, and after he received infliximab at a dose of (300mg) 2 weeks later, he showed a significant improvement both subjectively and objectively. He can move without assistance most of the time, the skin lesions became dry compared to their moist nature last week other than that no change in size or depth, his vital signs are stable compared with the time he were admitted to the ward, and he do not further have new complains.
· Condition Description, Predisposing Factors and Clinical Presentation
Behçet syndrome is characterized by is a multisystemic disease of unknown etiology characterized by chronic relapsing oral-genital aphthae, skin lesion, ocular disease, neurologic disease, vascular disease, or arthritis. This syndrome have been described by Hippocrates, but in 1937 Hulusi Behçet is the one who brought it to the attention of the modern medical community. (UptoDate.com, 2015)
As with other autoimmune disease, the underlining cause of the Behçet disease is still unknown. The disorder may embody the abnormal immune activity that triggered by exposure to factor, maybe infectious, in patients have a genetic predisposition to develop the disease.
There are several Predisposing factors of behcet syndrome, people who are I the second and third decades are more susceptible to experience the disease, older people and children are less expected to get the disease. Behcet disease can effect both genders however it is often more intense in males as compared to females. Sometimes genes play an important role to develop behcet disease in case he or she has specific genes linked with the condition. (UptoDate.com, 2015)
Despite the fact that Mr,S first symptom was the eyes impairment, painful mucocutaneous ulcers consider as the first common clinical feature of behcet syndrome. The spectrum of clinical manifestations are variable in different populations which mean that it is not requirement that all the patients sharing the same manifestation of the disorder. Ocular disease characterized as the most causative agent of morbidity and mortality. Vasculitis also is considered as the underlying nature of behcet syndrome. The concept of vasculo-behcet syndrome has been found for the cases the vascular involvement have the greatest involvement. Cerebral Venous Thrombosis (CVT) 10–20 % of BD patients has been found with CVT.” CVT is characterized by thrombosis of the venous sinuses”.
As I mentioned before, Behçet syndrome is charectrized by the ulcers, uveitis and other manustifation of disease such as skin and GI lesions, arthritis, CNS involvement and vascular lesion.