Download CASE CONFERENCE APRIL 17 th 2012

LSU INTERNAL MEDICINE CASE
CONFERENCE
CASE CONFERENCE
APRIL 17th 2012
Raisa C. Martínez, M.D.
Neurology PGY-1
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
 Endometriosis
 Vitiligo
 Chronic pelvic pain
 Irritable bowel disease after
bowel resection
Medications:
 None
Allergies
 None
Past Surgical History
 Ectopic pregnancy resection
 Chocolate cyst removal x 2
 Partial hysterectomy secondary to endometriosis
 Ex-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 History
 Non-contributory
Social History
 One pack of cigarettes weekly x 15 years
 Occasional alcohol.
 Occasional marijuana use
 Regular diet
Review of Systems: (+)
 Gen: Decreased energy, feeling listless, decreased appetite, unintentional
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weight loss, lightheadedness
CV: chest pain, syncope, diaphoresis
Pulm: Progressive worsening shortness of breath x 2 months, especially
upon exertion x 2 weeks, wheezing
Endocrine: Increased desire for ice cold water, but no pica
GI: Nausea and emesis, alternating diarrhea and constipation
GU: Increased frequency with irritation upon urinating
Neuro: Generalized weakness without focal deficits
Heme: No easy bruising, soft tissue infections or edema
Review of Systems: (-)
 Gen: No fevers, chills or night sweats, no jaundice
 Eyes: No changes in vision, no photophobia
 ENT: No dysphagia, epistaxis or tinnitus
 CV: No palpitations
 Pulm: No cough with or without sputum, no paroxysmal nocturnal
dyspnea, no orthopnea
 GI: No abdominal pain or distension, no changes in stool color or caliber
 GU: No dysuria, no flank pain, no hematuria or vaginal discharge
 Neuro: No seizures, tremors or recurrent headaches
 Heme: No easy bruising, soft tissue infections or edema
Physical Exam:
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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.
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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…
10
140 103 10
3.4 26 0.39
Mg = 1.8
N = 3.0
82
L = 2.7
6.9
5.9
M = 0.1
Peripheral Smear:
32.8
+ tear drop cell
20.7
E = 0.1
Phos = 5.1
97.8
99
RBC = 2.12
MCH = 32.4
B=0
• Amylase = 19
• Lipase = 25
44
+ schistocytes
Hypochromic
Polychromasia
Tpro Alb Tbili AST AlkP ALT
7.4 4.9 3.2 154
Microcytes, macrocytes
Decreased platelets
77
11.6
• Hep Panel = (-)
• U/A: 1.008/7.0/+nitrites/+leukocytes/ many
bacteria, 3-5 wbc, 2-20 squam, 0 casts
21.1
1.0
D-dimer = 5640
Trop #1 = 0.03
LDH = 2730
Trop #2 = 0.03
Haptoglobin = 7
Retic % = 0.8
More laboratory work-up…
 Iron Profile:
Iron = 132
Transferrin = 238
TIBC = 309
Iron Sat = 43
• Vit B 12 = <12
• Ferritin = 177.5
• Folate = 15.8
• TSH = 1.45
• ANA = (-)
• Methylmalonic acid = 1363
• Homocysteine = 45
Chest CT Angiogram
 1. No evidence of intra-arterial pulmonary thrombus.
 2. No pulmonary mass, pneumothorax, pleural effusion, or
lymphadenopathy
 3. Mild cardiomegaly.
Abdominal U/S
 Hepatomegaly. 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 data
 Celiac Sprue = (-)
 Electrophoresis = Normal
 A = 95%
 A2 = 2.3%
 Intrinsic Factor AB = (+)
Hospital Course
 Day: 1-2
 Blood Transfusion x 2 with appropriate
response
 Hematology/Oncology Consult
 Vit B12 dose given
Diagnosis…
Vitamin B-12 Deficiency secondary to
Pernicious Anemia
Follow-Up…
 Patient received Vit B12 for 1-1/2 months
 At 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
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