Reza

Because a lot of people will just, they'll see the sodium and they'll go into treatment.

But no, like you got to first make sure you're solving the right problem.

So for me,

This is a subacute, progressive, inflammatory syndrome that's involving the mucus, the skin, a single joint, and the brain in a young patient with no medical history.

And now I'm wondering if that hip was actually, he did have some kind of joint problem, but now it's sort of a migratory oligoarthritis.

Now I'm saying all these buzzwords, I'm saying it slowly for something to trigger in Ravi's brain, but I would honestly, of all these findings, I would start with the ulcers.

They sound like aphthous ulcers, but there's several.

And they're not isolated.

Like all of us have experienced, or I think many of us have experienced an aphthous ulcer, but it doesn't come with bumps on the skin, with high fevers, with joint pain.

So then I went through my quick schema for like what can cause an oral ulcer, especially in a young patient.

And immediately I thought, could this be an STI?

And remember the thing with STIs is that the classic one we associate with ulcers is HSV.

People will tell you, oh, syphilis shanker doesn't cause ulcer or doesn't cause pain.

But the reality is many of these SEIs can coexist.

So, for example, could this patient have herpes simplex virus with gonococcal arthritis and maybe gonococcal rash?

It's a stretch, but it's important to consider once you mention ulcers.

The other big category to think about when you think about ulcers in the landscape of multisystemic disease is autoimmune conditions.

Immediately my mind went to inflammatory bowel disease.

And remember with inflammatory bowel disease, you do not need gastrointestinal symptoms.

This would be odd, but there are extra intestinal manifestation and it can absolutely involve the joint, involve the skin and cause ulcers, particularly Crohn's anywhere in the gastrointestinal tract.