Monday, 22 September 2008

A New Case For September

Dear Bloggers

The following case was provided to me for publication on this Blog. It has been anonymised to maintain patient confidentiality and is used to provide an example of Problem Based Learning of disease. I thank those wise physicians who made the diagnosis and who enlightened me about this case in a distant part of Japan.

This male patient presented to the outpatient clinic with the following symptoms:

• Cough and dyspnoea
• Facial swelling
• Arm and chest rash with pruritis
• Dull abdominal pain
• Finger numbness

History of Presenting Complaint

The cough began 1 month prior to admission and was productive of clear sputum and this symptom was mild.

The patient was becoming increasingly short of breath with wheezing and he was using his asthma medications without effect. On admission, his breathlessness was the worst he had ever experienced. He could normally walk most distances but prior to admission he was limited to only a few feet before encountering severe dyspnoea.

His face also began to swell especially around the right eyelid. There was a rash that was described on the left forearm that was red and itchy. The itchy rash spread to involve his upper chest and neck. Despite using an anti-histamine, the symptoms continued to progress.

5 days before admission he felt a dull pain in the right upper abdomen. The pain continued for several days and was 3/10 in severity. There was no radiation of the pain and he was still able to eat and drink. The patient was able to pass faeces and flatus normally and there was no constipation, diarrhoea or vomiting. The patient denied urinary symptoms and there was no back pain. He denied eating raw or poorly cooked food products.

The finger numbness was described like ‘pins and needles’ and affected only the distal aspects of his fingers. He did not have any symptoms in his feet. He denied any symptoms of diabetes mellitus (thirst, polyuria, lethargy) or high alcohol consumption, and he had a normal diet.

Previous History
• Chronic Sinusitis (30 years)
• Asthma (life long)
• Nasal polyp operation (8 years ago)
• Recurrent Urticarial-like skin rashes (from 5 years before)
• Recurrent Eyelid and Facial swelling (from 5 years before)
• Autoimmune Haemolytic Anaemia (AIHA) treated with steroid pulse therapy 3 years before.
• Urinary stones (5 years before)

• Epinastine HCl 20 mg (anti-histamine)
• Salmeterol 50 micrograms (inhaled)
• Fluticasone 20o micrograms (inhaled)

Family History
Mother had tuberculosis

Social History
Living independently in a house with his wife and 2 children.
Self-employed as an accountant.
Patient was a non-smoker and non-drinker.

Physical Examination
GCS 15/15. Alert. Temp 36.1 deg C, BP 100/60mmHg, HR 72 regular, Resp Rate 18/min, SpO2 88% breathing ambient room air.

General: Swollen face and obvious erythematous skin rash on left arm and chest. No JACCOL.

Eyes – pupils equal and reactive to light and accommodation, normal visual fields and no scotoma. Full range of extra-ocular muscle movements. No jaundice or anaemia.

Ears – Grossly normal externally. No auditory disturbance, Rinne’s and Weber’s test within normal limits. Tymanic membranes showed no redness, swelling and there was a normal cone of light.

Nose – no current maxillary or frontal sinus pain on palpation or percussion. Nasal examination not performed.

Throat – normal dentition, normal gums, normal tongue and mucosa. Pharynx not erythematous and no obvious swelling. Lymph nodes not palpable and thyroid within normal limits.

Cardiac: Apex located in 5 intercostal space in the left mid-axillary line, no heaves or thrills. Heart Sounds 1 & 2 normal with no 3rd or 4th heart sounds and no murmurs.

Respiratory: Trachea central and no ‘tracheal tug’. Expansion within normal limits (>5cm), percussion decreased at both bases. Wheeze throughout both lungs R>>>L. Few crackles at both bases.

Abdomen: Soft, flat, tender right hypochondrium and epigastrium. No rebound or tenderness.
No hepatosplenomegaly or masses. No hernial orifices. Bowel sounds normal. No renal angle tenderness.

CNS - described as grossly normal.

PNS – Tone, Power, Reflexes, Coordination normal throughout. Sensation decreased in the finger tips of both hands. Foot examination was within normal limits.

Laboratory Data ( )= normal range.
WBC 48 (35-91), Hb 12.4, MCV 93, Plts 447 (130-369), Na 141, K 3.7, Cl 106, BUN 5.4 (10-20), Creat 0.5 (0.4-0.8), CK 34 (11-140), Amylase 31 (43-116), AST 10 (8-38), ALT 7 (4-44), LDH 220 (123-251), ALP 307 (104-338), Total Bil 0.4 (0.3-1.1)

Chest Radiograph: Bilateral pleural effusions

Question 1: From the history, physical examination, radiology and laboratory data, please make a list of the positive findings.

Question 2: Please give a likely list of differential diagnoses based on your list generated in question 1.

Question 3: What tests would you perform to ascertain the diagnosis?

Questions 4: With the likeliest diagnosis in mind, what is the treatment of the disorder?

Please endeavour to have a go at answering the case. Submitted answers will be published anonymously (unless you otherwise specify), so if you have time then please have a go.