one for the doctors reading

An 8 yr old boy with an arthritis affecting both elbows and his left ankle. Marked pain swelling and restirction of movement.

symptoms and inflammatory markers settling after a course of herbal medicine and anti-inflamatories.

Bloods: 6/9/08:
CRP: 384 mg/L
ESR: 55
Rheumatoid factor: Positive

30/11/08
CRP: "negative"
ESR: 40
Rheumatoid factor: Negative
WCC: 8.9

I'm not sure how reliable the labs are nor what a constitutes a negative CRP?!

On examination he has marked swelling of a his right elbow and right ankle, only a little warm to the touch and moderately painful on all movements. Just about a ful range of movement at both.

Also He has an ejection systolic murmor radiating to his carotids, with no signs of symptoms of heart failure.

What is the next step: all ideas welcome............... further questions............?

La concepcion

is a volcano on the northern part of ometepe, and stands at 1610m tall. Fot the walking geeks amongst you that is 266m higher than be nevis.

Its a long climb. we started 2hrs late having found our guide laid out asleep in the bus shelter distinctly hung over. He called himself a guide, and to be fair he did know the way. However he struggle to keep up, was laid down and trying to sleep every time we stopped, and hadn't brought any food or water with him.

So we fed him and watered him and got him to the top, muttering and grumbling and looking more than a little sorry for himself. I don't think a canter up a mountain made for a good hangover cure.

The top was an incredible change of climate. Enshrouded in a near permanent cloud, we were drenched with what felt like a sharp sleet-like rain, driven by gale force winds up towards the crater. This while it was a still sunny day down at sea level.

The crater's edge was covered in warm ash, and the air was sulphorous and difficult to breathe - not a pleasant place.

There were some good views though