Fifth Case : At Last a Young Man

After solving the last case you woke up to find that whole peads thing was nothing but a dream and you are still working in ED . Feeling a mixture of emotions you set out for the Hospital and another boring day starts . . but something remarkable happens near lunch break. A 32-year-old man comes to you with a real mind twister. You take the history and learn that two weeks before coming to you, our patient awoke with discomfort in his right shoulder. Within a few days, the pain worsened significantly and involved both shoulders. He noted winging of the right scapula (figure). The pain was worse at night and was associated with a feeling of neck stiffness. Four days before evaluation, he noted a painful rash across his left shoulder. Because of superficial tenderness of the affected area, he avoided contact of the area by clothing. You also learn he had a past history of Crohn's disease.Now again you go for a PE

what you learn is this :

VITAL SIGNS
Temperature 99 F
Pulse 73 beats/minute
Blood pressure 128/82 mmHg
Respirations 17 breaths/minute
Oxygen saturation 98% on room air


Head Eyes & ENT:PERRL, EOMI , normal mucous membranes

NECK: Supple, nothing abnormal.

CARDIOVASCULAR: normal HR, regular rhythm without
rubs,murmurs or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, nontender,nondistended.


EXTREMITIES: No clubbing,cyanosis or edema.

NEUROLOGIC: The neurologic examination demonstrated only winging of the right scapula (Figure). There was a rash on an red base overlying the left scapula.

You go for investigations and find that the results of nerve conduction studies are normal. There were spontaneous fibrillation potentials but no motor unit potentials under voluntary control in the right serratus anterior muscle. Cerebrospinal fluid analysis showed five nucleated cells per microliter (85% lymphocytes, 9% mononuclear cells, 3% neutrophils, and 3% macrophages), increased protein concentration and a normal glucose level. Culture of the vesicular lesion came negative for herpes simplex and varicella-zoster virus (VZV).

Now whats your diagnosis?

How are you goin to proceed with everything?