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

One 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 ILLNESS

One 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

Hypertension Benign prostatic hypertrophy

Past Surgical History

Inguinal hernia repair 20 years prior to admission

Social History

Born 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.

Allergies

None

Outpatient Medications

Fosinopril 10mg daily Amlodipine 5mg daily Doxazosin 2mg at bedtime Ibuprofen prn Tylenol prn Guaifenesin 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 acute distress VITAL SIGNS BP 130/60, HR 82 and regular, RR 18, Temp 102.0, SpO 2 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)

PULMONARY Clear to auscultation bilaterally HEART Normal heart sounds, regular rhythm, no murmurs ABDOMINAL Normal bowel sounds, soft, non-tender, non-distended EXTREMITIES No peripheral edema, 2+ peripheral pulses SKIN No rashes RECTAL Mild symmetric enlarged prostate, no masses, guaiac negative

Physical Exam (3)

NEURO Alert and oriented to person, place and time Gait 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 foot Deep Tendon Reflexes: 1+ patellar, 1+ achilles bilaterally; 2+ upper extremities bilaterally Babinski: flexor response, downgoing toes bilaterally

Test HEMATOLOGY

Hemoglobin (g/dl) Hematocrit (%) White-cell count (per mm 3 ) Differential Count (%) Neutrophils Lymphocytes Monocytes Eosinophils Mean Corpuscular Volume (µm 3 ) Platelet Count (per mm 3 ) ESR (mm/hr) PTT (sec) PT (sec)

Ref Range 1 Year Ago Admission

13.5 – 17.5

41.0 – 53.0

4,500 – 11,000 14.0

40.0

6,200 40 – 70 22 – 44 4 – 11 0 – 8 80 – 100 150,000 – 300,000 0 – 17 22.1 – 35.1

11.3 – 13.3

210,000 10.1

30.6

10,300 78 6 8 2 85 411,000 70 31 12.1

CHEMISTRY Test

Sodium (mmol/liter) Potassium (mmol/liter) Chloride (mmol/liter) Carbon dioxide (mmol/liter) Urea nitrogen (mg/dl) Creatinine (mg/dl) Calcium (mg/dl) Magnesium (mmol/liter) Phosphorus (mmol/liter)

Ref Range 1 Year Ago

135 – 145 141 3.4 – 4.8

100 – 108 23.0 – 31.9

8 – 25 0.6 – 1.5

8.5 – 10.5

0.7 – 1.0

2.6 – 4.5

4.5

107 27 17 0.9

8.8

Admission

137 4.9

108 22 42 1.4

7.6

1.9

3.0

CHEMISTRY/SEROLOGY Test

AST (U/liter)

Ref Range

10 – 40 ALT (U/liter) Total Bilirubin (g/dl) Direct Bilirubin (g/dl) 10 – 55 0.0 – 1.0

0.0 – 0.4

Total Protein (g/dl) Albumin (g/dl) 6.0 – 8.3

2.6 – 4.1

Alkaline Phosphatase (U/liter) 45 – 115 Lactate Dehydrogenase 110 - 225 Antinuclear Antibody Rheumatoid Factor (IU/ml) Negative < 15 Creatine Phosphokinase Aldolase 45-245 0-7

1 Year Ago

20 23 0.6

0.1

7.3

4.1

65

Admission

75 128 0.5

0.1

6.2

3.1

116 211 + (< 1:40) 79.2

43 7.5

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