CASE CONFERENCEAPRIL 17th 2012

Raisa C. Martínez, M.D.Neurology PGY-1

LSU INTERNAL MEDICINE CASE CONFERENCE

Chief Complaint

“My chest hurts and I’ve been having trouble breathing.”

History of Present Illness

This is a 46-year-old woman with PMHx of vitiligo, endometriosis, and irritable bowel syndrome, who was in her usual state of health until 2 months prior to admission when she started feeling short of breath, tired and weak.

The patient does report one episode of feeling light headed about 2 months ago in Atlanta while walking her dog. She thought that she was going to pass out but did not lose consciousness.

Following this episode she went to the ED where a work-up failed to explain her symptoms.

She moved to New Orleans about one month prior to admission. Her symptoms continued to worsen She also began to experience intermittent chest pain and shortness of breath that was more pronounced with exertion. Worsening of these symptoms prompted the patient to present to the emergency department.

HPI (continued)…

She described her chest pain as: left sided in location; 6-7/10 in intensity; radiated to the neck and left arm; and associated with shortness breath, nausea, diaphoresis. She also described an uncomfortable sensation pressing against her left collar bone.

Always tired….Denied fever, chills, or cough. No headache. No

hemoptysis or gum bleeding. No vaginal bleeding. No dark tarry stools or blood in her stool. She has noticed that the white of her eyes have become yellow.

Past Medical History

EndometriosisVitiligoChronic pelvic painIrritable bowel

disease after bowel resection

Medications:NoneAllergiesNone

Past Surgical History

Ectopic pregnancy resectionChocolate cyst removal x 2Partial hysterectomy secondary to

endometriosisEx-lap with lysis of adhesion secondary to prior

abdominal procedures as well as resection of a portion of bowel. The location is unknown to the patient (as per the patient about 8 cms of length of her bowel was removed).

Family HistoryNon-contributory

Social HistoryOne pack of cigarettes weekly x 15 years Occasional alcohol. Occasional marijuana useRegular diet

Review of Systems: (+)

Gen: Decreased energy, feeling listless, decreased appetite, unintentional weight loss, lightheadedness

CV: chest pain, syncope, diaphoresis Pulm: Progressive worsening shortness of breath x 2

months, especially upon exertion x 2 weeks, wheezingEndocrine: Increased desire for ice cold water, but no

pica GI: Nausea and emesis, alternating diarrhea and

constipationGU: Increased frequency with irritation upon urinatingNeuro: Generalized weakness without focal deficitsHeme: No easy bruising, soft tissue infections or edema

Review of Systems: (-)

Gen: No fevers, chills or night sweats, no jaundiceEyes: No changes in vision, no photophobiaENT: No dysphagia, epistaxis or tinnitusCV: No palpitationsPulm: No cough with or without sputum, no paroxysmal

nocturnal dyspnea, no orthopnea GI: No abdominal pain or distension, no changes in

stool color or caliberGU: No dysuria, no flank pain, no hematuria or vaginal

dischargeNeuro: No seizures, tremors or recurrent headachesHeme: No easy bruising, soft tissue infections or edema

Physical Exam:

VITAL SIGNS: BP-118/84 HR-103 Temp- 98.3 O2 sats on RA-98% GENERAL: AAO x3. No apparent distress. HEENT: Positive minimal scleral icterus, and in the soft palate and

hypoglossal fossa as well No appreciated thyromegaly or cervical lymphadenopathy. No paranasal tenderness. No oropharyngeal erythema or exudate. Moist mucous membranes. Positive skin change and vitiligo to the face. PERRL. EOMI CARDIOVASCULAR: Regular rate and rhythm. S1, S2 normal. No

murmurs,rubs, or gallops appreciated on auscultation. RESPIRATORY: Clear to auscultation bilaterally. No wheezes, rales, or

crackles appreciated.

Physical Exam (continued)…

ABDOMEN: Nondistended. Positive bowel sounds. No hepatosplenomegaly appreciated; nontender to palpation.

EXTREMITIES: No cyanosis, clubbing, or edema. 2+ pulses x4 extremities. Poor capillary refill with resting pallor, positive vitiliginous changes to the bilateral upper extremities and lower extremities with islands of amelanotic patches surrounded by hyperpigmented areas. No rashes, no petechiae.

Physical Exam (continued)…

Chest X-ray

EKG

Laboratory Work Up…

20.7995.9

97.8

32.8

Tpro Alb Tbili AST AlkP ALT

N = 3.0

L = 2.7

M = 0.1

E = 0.1

B = 0

140 3.4

10326

10

0.3982

10

7.4 4.9 3.2 154 44 77

• U/A: 1.008/7.0/+nitrites/+leukocytes/ many bacteria, 3-5 wbc, 2-20 squam, 0 casts

Trop #1 = 0.03

Trop #2 = 0.03

Peripheral Smear:

Microcytes, macrocytes

+ tear drop cell

+ schistocytes

Hypochromic

Polychromasia

Decreased platelets

• Amylase = 19• Lipase = 25

1.0

11.6 21.1

6.9

Mg = 1.8 Phos = 5.1 RBC = 2.12MCH = 32.4

• Hep Panel = (-)

D-dimer = 5640

LDH = 2730

Haptoglobin = 7

Retic % = 0.8

More laboratory work-up… Iron Profile:

Iron = 132

Transferrin = 238

TIBC = 309

Iron Sat = 43

• Methylmalonic acid = 1363• Homocysteine = 45

• Vit B 12 = <12• Ferritin = 177.5• Folate = 15.8

• TSH = 1.45• ANA = (-)

Chest CT Angiogram1. No evidence of intra-arterial pulmonary

thrombus. 2. No pulmonary mass, pneumothorax,

pleural effusion, or lymphadenopathy 3. Mild cardiomegaly.

Abdominal U/SHepatomegaly. Heterogeneous hepatic

echotexture. This limits evaluation of the underlying hepatic parenchyma and therefore detection of focal abnormality. Further evaluation with contrast-enhanced MRI or CT can be performed as clinically warranted.

The SPLEEN is normal in size and appearance , measuring 11-12 cm.

The left KIDNEY is normal borderline size measuring 13.1 cm. thickness of the parenchyma is normal. No stones are seen. There is no evidence of hydronephrosis. No significant solid masses are noted.

Peripheral Blood Smear

Additional lab dataCeliac Sprue = (-)Electrophoresis = NormalA = 95%A2 = 2.3%

Intrinsic Factor AB = (+)

Hospital CourseDay: 1-2

Blood Transfusion x 2 with appropriate response

Hematology/Oncology Consult

Vit B12 dose given

Vitamin B-12 Deficiency secondary to Pernicious

Anemia

Diagnosis…

Follow-Up…Patient received Vit B12 for 1-1/2 monthsAt present time the patient’s vitamin B12 levels

are within normal limits. The patient will require vitamin B12 for the rest

of her life and should take 1000 mcg of vitamin B12 subcutaneously every month

THANK YOU