clinical pathological conference danise schiliro-chuang, m.d. chief resident department of medicine...

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Clinical Pathological Clinical Pathological Conference Conference Danise Schiliro-Chuang, M.D. Danise Schiliro-Chuang, M.D. Chief Resident Chief Resident Department of Medicine Department of Medicine September 14, 2007 September 14, 2007

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Clinical Pathological Clinical Pathological ConferenceConference

Danise Schiliro-Chuang, M.D.Danise Schiliro-Chuang, M.D.Chief Resident Chief Resident

Department of MedicineDepartment of MedicineSeptember 14, 2007September 14, 2007

CHIEF COMPLAINTCHIEF COMPLAINT

A 73 year-old Hispanic male presents with A 73 year-old Hispanic male presents with

recurrent fevers, generalized weakness andrecurrent fevers, generalized weakness and

myalgia for one month.myalgia for one month.

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

One month prior to admission: new onset weakness One month prior to admission: new onset weakness and myalgia and myalgia

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

Subjective fevers, marked by chills and night sweats Subjective fevers, marked by chills and night sweats

Moderate to severe fatigueModerate to severe fatigue

7-8 Ib weight loss7-8 Ib weight loss

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

One day prior to admission: seen by One day prior to admission: seen by primary care physician, routine labs drawnprimary care physician, routine labs drawn

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

Past Medical HistoryPast Medical History HypertensionHypertensionBenign prostatic hypertrophyBenign prostatic hypertrophy

Past Surgical HistoryPast Surgical HistoryInguinal hernia repair 20 years prior to admissionInguinal hernia repair 20 years prior to admission

Social HistorySocial HistoryBorn in Ecuador, in the U.S. for > 30 years, last traveled Born in Ecuador, in the U.S. for > 30 years, last traveled

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

AllergiesAllergiesNoneNone

Outpatient MedicationsOutpatient Medications Fosinopril 10mg dailyFosinopril 10mg dailyAmlodipine 5mg dailyAmlodipine 5mg dailyDoxazosin 2mg at bedtimeDoxazosin 2mg at bedtimeIbuprofen prnIbuprofen prnTylenol prnTylenol prnGuaifenesin prnGuaifenesin prn

Review of SystemsReview of Systems

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

Physical ExamPhysical Exam

GENERALGENERAL Chronic ill-appearing man, appears stated age, no acuteChronic ill-appearing man, appears stated age, no acutedistressdistress

VITAL SIGNSVITAL SIGNS BP 130/60, HR 82 and regular, RR 18, Temp 102.0, SpOBP 130/60, HR 82 and regular, RR 18, Temp 102.0, SpO22

97% room air, Wt 150 Ibs, BMI 2497% room air, Wt 150 Ibs, BMI 24

HEENTHEENT Oropharynx clearOropharynx clear

LYMPHLYMPH No cervical, axillary or inguinal lymphadenopathy No cervical, axillary or inguinal lymphadenopathy

NECKNECK Supple, no jugular venous distensionSupple, no jugular venous distension

Physical Exam (2)Physical Exam (2)

PULMONARYPULMONARYClear to auscultation bilaterallyClear to auscultation bilaterally

HEARTHEARTNormal heart sounds, regular rhythm, no murmursNormal heart sounds, regular rhythm, no murmurs

ABDOMINALABDOMINALNormal bowel sounds, soft, non-tender, non-distendedNormal bowel sounds, soft, non-tender, non-distended

EXTREMITIESEXTREMITIESNo peripheral edema, 2+ peripheral pulsesNo peripheral edema, 2+ peripheral pulses

SKINSKINNo rashesNo rashes

RECTALRECTALMild symmetric enlarged prostate, no masses, guaiac negativeMild symmetric enlarged prostate, no masses, guaiac negative

Physical Exam (3)Physical Exam (3)

NEURONEURO- Alert and oriented to person, place and timeAlert and oriented to person, place and time- Gait slow, unsteady; no tremor/spasticity/rigidity Gait slow, unsteady; no tremor/spasticity/rigidity - Cranial nerves II-XII intact Cranial nerves II-XII intact - Upper extremities: 5/5 motor strength, decreased right wrist Upper extremities: 5/5 motor strength, decreased right wrist

flexion, decreased right hand grasp flexion, decreased right hand grasp - Lower extremities: hip flexors 3/5 motor strength (right) and Lower extremities: hip flexors 3/5 motor strength (right) and

4/5 (left), quadriceps 3/5 motor strength (right) and 4/5 (left)4/5 (left), quadriceps 3/5 motor strength (right) and 4/5 (left)- Sensory: decreased sensation right dorsal footSensory: decreased sensation right dorsal foot- Deep Tendon Reflexes: 1+ patellar, 1+ achilles bilaterally; 2+ Deep Tendon Reflexes: 1+ patellar, 1+ achilles bilaterally; 2+

upper extremities bilaterallyupper extremities bilaterally- Babinski: flexor response, downgoing toes bilaterallyBabinski: flexor response, downgoing toes bilaterally

Test Ref Range 1 Year Ago Admission

HEMATOLOGY

Hemoglobin (g/dl) 13.5 – 17.5 14.0 10.1

Hematocrit (%) 41.0 – 53.0 40.0 30.6

White-cell count (per mm3) 4,500 – 11,000 6,200 10,300

Differential Count (%)

Neutrophils 40 – 70 78

Lymphocytes 22 – 44 6

Monocytes 4 – 11 8

Eosinophils 0 – 8 2

Mean Corpuscular Volume (µm3) 80 – 100 85

Platelet Count (per mm3) 150,000 – 300,000

210,000 411,000

ESR (mm/hr) 0 – 17 70

PTT (sec) 22.1 – 35.1 31

PT (sec) 11.3 – 13.3 12.1

CHEMISTRY

Test Ref Range 1 Year Ago Admission

Sodium (mmol/liter) 135 – 145 141 137

Potassium (mmol/liter) 3.4 – 4.8 4.5 4.9

Chloride (mmol/liter) 100 – 108 107 108

Carbon dioxide (mmol/liter) 23.0 – 31.9 27 22

Urea nitrogen (mg/dl) 8 – 25 17 42

Creatinine (mg/dl) 0.6 – 1.5 0.9 1.4

Calcium (mg/dl) 8.5 – 10.5 8.8 7.6

Magnesium (mmol/liter) 0.7 – 1.0 1.9

Phosphorus (mmol/liter) 2.6 – 4.5 3.0

CHEMISTRY/SEROLOGY

Test Ref Range 1 Year Ago AdmissionAST (U/liter) 10 – 40 20 75

ALT (U/liter) 10 – 55 23 128

Total Bilirubin (g/dl) 0.0 – 1.0 0.6 0.5

Direct Bilirubin (g/dl) 0.0 – 0.4 0.1 0.1

Total Protein (g/dl) 6.0 – 8.3 7.3 6.2

Albumin (g/dl) 2.6 – 4.1 4.1 3.1

Alkaline Phosphatase (U/liter)

45 – 115 65 116

Lactate Dehydrogenase 110 - 225 211

Antinuclear Antibody Negative + (< 1:40)

Rheumatoid Factor (IU/ml) < 15 79.2

Creatine Phosphokinase 45-245 43

Aldolase 0-7 7.5

Urinalysis: pH 5.5, yellow, clear, negative Urinalysis: pH 5.5, yellow, clear, negative glucose/bilirubin/ketones/nitrites/leukesterase; glucose/bilirubin/ketones/nitrites/leukesterase; 1+ blood; 1+ protein; 0-2 WBC; 5-10 RBC1+ blood; 1+ protein; 0-2 WBC; 5-10 RBC

Blood Cultures x 2 – no growthBlood Cultures x 2 – no growth

Urine Culture – no growthUrine Culture – no growth

EKG

A Diagnostic Procedure Was PerformedA Diagnostic Procedure Was Performed