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Clinical Pathological Conference. Danise Schiliro-Chuang, M.D. Chief Resident Department of Medicine September 14, 2007. CHIEF COMPLAINT. A 73 year-old Hispanic male presents with recurrent fevers, generalized weakness and myalgia for one month. HISTORY OF PRESENT ILLNESS. - PowerPoint PPT Presentation

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  • Clinical Pathological ConferenceDanise Schiliro-Chuang, M.D.Chief Resident Department of MedicineSeptember 14, 2007

  • CHIEF COMPLAINT

    A 73 year-old Hispanic male presents with recurrent fevers, generalized weakness andmyalgia for one month.

  • HISTORY OF PRESENT ILLNESSOne month prior to admission: new onset weakness and myalgia

    Weakness generalized with particular involvement of the lower extremities. Difficulties climbing stairs and rising from a seated position due to weakness and diffuse lower extremity pain

    Subjective fevers, marked by chills and night sweats

    Moderate to severe fatigue

    7-8 Ib weight loss

  • HISTORY OF PRESENT ILLNESSOne day prior to admission: seen by primary care physician, routine labs drawn

    Day of admission: called to emergency room for a significant decrease in hematocrit from 1 year prior

  • Past Medical History HypertensionBenign prostatic hypertrophy

    Past Surgical HistoryInguinal hernia repair 20 years prior to admission

    Social HistoryBorn in Ecuador, in the U.S. for > 30 years, last traveled outside the U.S. to Ecuador >20 years ago. 5 pack-year tobacco history, quit 30 years ago. No alcohol use. No elicit drug use. Lives with wife. Retired painter, construction worker.

  • AllergiesNone

    Outpatient Medications Fosinopril 10mg dailyAmlodipine 5mg dailyDoxazosin 2mg at bedtimeIbuprofen prnTylenol prnGuaifenesin prn

  • Review of Systems

    Persistent mild dry cough without sputum production or hemoptysis x 3-4 weeks

  • Physical Exam

    GENERAL Chronic ill-appearing man, appears stated age, no acutedistress

    VITAL SIGNS BP 130/60, HR 82 and regular, RR 18, Temp 102.0, SpO2 97% room air, Wt 150 Ibs, BMI 24

    HEENT Oropharynx clear

    LYMPH No cervical, axillary or inguinal lymphadenopathy

    NECK Supple, no jugular venous distension

  • Physical Exam (2)

    PULMONARYClear to auscultation bilaterally

    HEARTNormal heart sounds, regular rhythm, no murmurs

    ABDOMINALNormal bowel sounds, soft, non-tender, non-distended

    EXTREMITIESNo peripheral edema, 2+ peripheral pulses

    SKINNo rashes

    RECTALMild symmetric enlarged prostate, no masses, guaiac negative

  • Physical Exam (3)

    NEUROAlert and oriented to person, place and timeGait slow, unsteady; no tremor/spasticity/rigidity Cranial nerves II-XII intact Upper extremities: 5/5 motor strength, decreased right wrist flexion, decreased right hand grasp Lower extremities: hip flexors 3/5 motor strength (right) and 4/5 (left), quadriceps 3/5 motor strength (right) and 4/5 (left)Sensory: decreased sensation right dorsal footDeep Tendon Reflexes: 1+ patellar, 1+ achilles bilaterally; 2+ upper extremities bilaterallyBabinski: flexor response, downgoing toes bilaterally

  • TestRef Range1 Year AgoAdmissionHEMATOLOGYHemoglobin (g/dl)13.5 17.514.010.1Hematocrit (%)41.0 53.040.030.6White-cell count (per mm3)4,500 11,0006,20010,300Differential Count (%) Neutrophils40 7078 Lymphocytes22 446 Monocytes4 118 Eosinophils0 82Mean Corpuscular Volume (m3)80 10085Platelet Count (per mm3)150,000 300,000210,000411,000ESR (mm/hr)0 1770PTT (sec)22.1 35.131PT (sec)11.3 13.312.1

  • CHEMISTRYTestRef Range1 Year AgoAdmissionSodium (mmol/liter)135 145141137Potassium (mmol/liter)3.4 4.84.54.9Chloride (mmol/liter)100 108107108Carbon dioxide (mmol/liter)23.0 31.92722Urea nitrogen (mg/dl)8 251742Creatinine (mg/dl)0.6 1.50.91.4Calcium (mg/dl)8.5 10.58.87.6Magnesium (mmol/liter)0.7 1.01.9Phosphorus (mmol/liter)2.6 4.53.0

  • CHEMISTRY/SEROLOGYTestRef Range1 Year AgoAdmissionAST (U/liter)10 402075ALT (U/liter)10 5523128Total Bilirubin (g/dl)0.0 1.00.60.5Direct Bilirubin (g/dl)0.0 0.40.10.1Total Protein (g/dl)6.0 8.37.36.2Albumin (g/dl)2.6 4.14.13.1Alkaline Phosphatase (U/liter)45 11565116Lactate Dehydrogenase110 - 225211Antinuclear AntibodyNegative+ (< 1:40)Rheumatoid Factor (IU/ml)< 1579.2Creatine Phosphokinase 45-24543Aldolase0-77.5

  • Urinalysis: pH 5.5, yellow, clear, negative glucose/bilirubin/ketones/nitrites/leukesterase; 1+ blood; 1+ protein; 0-2 WBC; 5-10 RBC

    Blood Cultures x 2 no growth

    Urine Culture no growth

  • EKG

  • A Diagnostic Procedure Was Performed

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