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