[37M] With multiple neurological and systemic symptoms post-cholecystectomy
Patient Description
A 37-year-old male presents with a range of symptoms that began immediately after a laparoscopic cholecystectomy. The primary concerns include difficulty retaining and recalling memories, delirium, and psychosis. These memory issues occur 2-3 times a month and last 1-2 weeks, significantly affecting his ability to work. Additionally, he experiences systemic tremors, mostly in his hands, buttocks, shoulders, and arms, for the past 6 months. He reports numbness and tingling in his fingers and toes, which turn dark red/purple beyond the first knuckle, ongoing for 3-4 weeks, affecting his dexterity. Severe joint pain in his fingers, wrists, elbows, knees, toes, neck, and back has been present for approximately 1.5 months, accompanied by stiffness, redness, and sometimes pinkish-brown nodules near the joints. A dry, flaky, scaly rash is noted across the bridge of his nose, extending to his cheeks and forehead. He also reports low-grade fever, nausea, severe edema in his torso, shoulders, abdomen, and back, occasional seizures, atrial fibrillation (A-Fib), a right to left atrial shunt, and a previous cerebrovascular accident (CVA). Significant fatigue without weight loss, purple discoloration of fingers and toes with a distinct line demarcating the purple from white, severe headaches often associated with seizures, lasting from 1 hour to 36 hours, causing photosensitivity, difficulty reading with letters becoming doubled and incorrect words being perceived, severe insomnia lasting up to 92 hours, raw, tender spots on the roof of his mouth, occasional cold sores, and a possible cyst on the posterior of his right forearm noticed 4 days ago are also reported. His pre-existing conditions include hypertension, asthma, and PTSD, all diagnosed in 2012. He is allergic to amoxicillin and avoids opiates, barbiturates, and benzodiazepines. Current medications include Losartan, Metoprolol, Depakote, Zoloft, Trazodone, Xopenex, Symbicort, Hydroxyzine, and Gabapentin, with some being new additions in the past 60 days. He occasionally uses THC and has a family history of rheumatoid arthritis in an uncle.
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Arora's Assessment
What might be happening
It is likely that your symptoms are related to multiple issues, including existing diagnoses. If you have more questions, we can continue chatting.
Memory Issues, Delirium, and Psychosis
- Postoperative Cognitive Dysfunction (POCD): Given that your memory issues, delirium, and psychosis began immediately after your laparoscopic cholecystectomy, POCD is a possible cause. This condition can occur after surgery, especially in older adults or those with pre-existing cognitive issues.
- Medication Side Effects: New medications like Metoprolol, Depakote, and Hydroxyzine could potentially contribute to cognitive issues.
Numbness, Tingling, and Joint Pain
- Peripheral Neuropathy: The numbness and tingling in your fingers and toes, along with the purple discoloration, could be due to peripheral neuropathy. This condition can be caused by various factors, including diabetes, vitamin deficiencies, or autoimmune diseases.
- Raynaud's Phenomenon: The color changes in your fingers and toes, especially with a distinct line demarcating the purple from white, suggest Raynaud's phenomenon, which is often associated with autoimmune conditions.
- Inflammatory Arthritis: The severe joint pain, stiffness, redness, and nodules near the joints could indicate an inflammatory arthritis condition, such as rheumatoid arthritis or lupus.
Rash and Skin Changes
- Lupus: The dry, flaky, scaly rash across the bridge of your nose and extending to your cheeks and forehead is characteristic of a "butterfly rash," which is often seen in lupus.
- Dermatomyositis: The rash, along with muscle weakness and joint pain, could also suggest dermatomyositis, an inflammatory condition affecting the skin and muscles.
Fatigue, Fever, and Nausea
- Chronic Inflammatory Response: The combination of fatigue, low-grade fever, and nausea could be due to a chronic inflammatory response, possibly related to an autoimmune condition.
Seizures and Headaches
- Neurological Conditions: The seizures, severe headaches, and photosensitivity could be related to a neurological condition, such as epilepsy or an autoimmune encephalitis.
Edema and Cardiovascular Issues
- Heart Failure or Fluid Retention: The severe edema in your torso, shoulders, abdomen, and back could be due to heart failure or fluid retention, possibly exacerbated by your atrial fibrillation and right-to-left atrial shunt.
What you can do
Memory Issues, Delirium, and Psychosis
- See a Doctor: Consult a neurologist or your primary care physician to evaluate your cognitive symptoms. They may recommend neuroimaging, cognitive testing, or a review of your medications.
- Medication Review: Discuss with your doctor the possibility of medication side effects contributing to your symptoms.
Numbness, Tingling, and Joint Pain
- See a Rheumatologist: Given the possibility of autoimmune conditions, a rheumatologist can help diagnose and manage conditions like lupus or rheumatoid arthritis.
- Home Care: Keep your hands and feet warm to manage Raynaud's symptoms. Gentle exercises and stretching can help with joint stiffness.
Rash and Skin Changes
- Dermatologist Consultation: A dermatologist can evaluate your skin rash and recommend appropriate treatments.
- Skin Care: Use gentle, hydrating skincare products to manage dryness and flakiness.
Fatigue, Fever, and Nausea
- Monitor Symptoms: Keep track of your symptoms using the MDandMe journal to identify any patterns or triggers.
- Healthy Lifestyle: Ensure adequate rest, hydration, and a balanced diet to support your overall health.
Seizures and Headaches
- Neurologist Consultation: A neurologist can help manage your seizures and headaches, possibly adjusting your medications or recommending additional treatments.
- Avoid Triggers: Identify and avoid potential seizure and headache triggers, such as stress, lack of sleep, or certain foods.
Edema and Cardiovascular Issues
- Cardiologist Consultation: Given your history of atrial fibrillation and right-to-left atrial shunt, a cardiologist can help manage your cardiovascular health and address the edema.
- Compression Garments: Wearing compression stockings or garments can help manage edema.
What you should look out for
Given the complexity and severity of your symptoms, you should seek medical care as soon as possible. Reasons to seek care even more urgently include:
- Severe or Worsening Symptoms: If any of your symptoms significantly worsen or new severe symptoms develop.
- Neurological Changes: Sudden changes in vision, speech, or motor function.
- Cardiovascular Symptoms: Chest pain, shortness of breath, or
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5 mo ago