Friday, 16 January 2009

January's Case

Dear Bloggers

Here is an anonymised case for January. Please have a go! Drop me your opinions on the case and we can see if your are right!

This 80 year old female presented with a two month history of the following symptoms:
  • Fever
  • Sweats
  • Fatigue
  • Weight Loss
  • Numbness of her feet
  • Dyspnoea
The symptoms started abruptly two months before with onset of fever. The patient took her own temperature which was about 38 degrees Celsius. She was unable to say if there was day-night variation in the fever. There were no associated chills or rigors.

The patient noticed sweating, albeit intermittently, and only when she had the fever. She denied drenching night sweats.

The fatigue was apparent from the outset and continued throughout the two months prior to and during the admission to hospital. There was associated weight loss noticed by the patient with her clothes feeling larger on her and her wedding ring becoming loose.

The numbness occurred initially in both her hands and feet and became constant in the latter and disappeared in the former after several weeks. On admission, she complained of only foot numbness up to the ankle area.

The patient also noticed worsening dyspnoea especially on exertion. She denied orthopnea, cough, sputum, wheeze, haemoptysis.

On further questioning she admitted to further symptoms of
  • Initial headache: this headache occurred at the beginning of the symptom complex. She was unable to denote the severity on the pain scale. There was no throbbing nature to the pain but she did admit to an unusual feeling on her scalp. There was no visual disturbance, no jaw or tongue claudication.
  • Leg Pain: she admitted to initial upper leg pain which soon disappeared. There was no complaint of this on admission. The patient did not complain of weakness.
  • Shoulder Pain: this was apparently a long standing problem going back several years and had not worsened prior to or during the admission.
The patient had initially been admitted to a local clinic for investigation and treatment. It was suspected that the patient had an "infection" and she was commenced on piperacillin and sulbactam without improvement of symptoms or resolution of the fever. She was referred to another hospital for further investigation.

Previous Medical History
  • Hypertension
  • Impaired Glucose Tolerance
  • Insomnia
  • Rampiril 10mg/day
  • Diazepam 5mg once nocte
Family History

Nothing relevant

Social History & Habits

She lived with her family. Her husband was deceased. She was an ex-smoker although only recently having given up.
She did not consume alcohol and had never received a blood transfusion, tattoos or needle stick injury.

She had no pets and had never travelled abroad.

Review of Body Systems (questions to patient only; no physical exam at this stage)

CVS: No palpitations, chest pain, leg pain on walking
RESP: as above. No sinus pain, no epistaxis,
ABDO: No abdominal pain or swelling. No nausea, vomiting, diarrhoea, constipation, malena, haematochezia or jaundice.
MUSC-SKEL: No muscle or bone pain. No joint swelling or morning stiffness.
URO-GEN: No urinary symptoms or vaginal discharge. No post-menopausal bleeding. No change in the colour of her urine.
CNS-PNS: No visual disturbance, no hearing disturbance, no speech disturbance. No weakness or other new sensory disturbances. No seizures in the past.
ENDO: No polyuria, polydipsia. No alteration in hot or cold tolerance. No history of renal stones.
SKIN: No complaints.

On Examination

General: She appeared chronically unwell. She was alert, conversant although unclear with precise history. She appeared sweaty. Conjunctivae appeared pale. No cyanosis.

Lymph Nodes: Non-tender lymphadenopathy was present at both jugulodigastric nodes and small, fixed 'shotty' nodes in the groins.

Mouth: large, 2x3 cm mass arising from the hard palate. Pink colour, smooth, no ulceration or bleeding. Patient denied trauma to the identified area.

CVS: Pulse 140 per minute, irregulary irregular with low volume quality. It was not possible to ascertain collapse or slow rising nature. BP 120/70mmHg in the right arm in the supine position. Sitting BP was not performed. JVP was 5cm and with an irregular peak in keeping with the irregular pulse. Quinke's sign was positive.
Heart sounds 1 & 2 were present with no obvious 3rd or 4th sound. No murmur evident. There were no carotid bruits.
Legs revealed pitting oedema >40 seconds in the posterior ankle region. There was no clinical evidence of DVT.

RESP: Resp Rate 26 per minute and regular. SpO2 93% on ambient room air. Trachea central with two-fingers appliable to the suprasternal notch. The chest was mildly hyper-expanded, dull to percussion bilaterally at the bases with 'wet' early crackles.

ABDO: Soft, flat, non-tender. No hepatosplenomegaly, no ascites. Bowel sounds normal. Renal angles revealed no tenderness. Rectal exam - no masses and blood was absent.

MUSC-SKEL: No joint pain or swelling on passive movement in any of the large or small joints. Muscles revealed no tenderness.

Tone: Normal throughout in upper and lower limbs.
Power: Normal 5/5 throughout
Reflexes: Normal throughout in upper and lower limbs.
Coordination: Within normal limits
Sensation: Indeterminate change in hands for light touch; loss of light touch in soles and dorsum of both feet. Temperature, nociception, vibration not measured.
Babinski: negative bilaterally (flexor plantar)

II: bilateral cataracts, normal constriction to light and accommodation. Visual fields difficult to accurately determine but grossly within normal limits for age.
III / IV / VI: Within normal limits
V: Motor and Sensory within normal limits
VII / VIII / IX / X / XI / XII: Within normal limits

No cerebellar signs.

Lab Studies

Hb 8.6, WBC 6.6, MCV 92, Plts 24.6 (normal). AST / ALT / gamma-GT / Bilirubin within normal limits. ALP 432 (ALP 1 iso-enzyme elevated). BUN and Creatinine within normal limits. Creatinine Kinase (CK) within normal limits.

Serum electrophoresis normal. Bence Jones protein not tested.

Coagulation normal. Urinalysis normal except for trace of protein.

ESR >100mm/hr.

HBV and HCV negative.

Chest Xray: Bilateral small effusions. Hyper-expansion. Cardiac silhouette slightly enlarged. No mass lesions or bone erosions.

CT of Chest and Abdomen: Bilateral effusions. A small area of fibrotic change in the right anterior lung. Normal amount of pericardial fluid. No mass lesion identified. Liver normal looking. Spleen normal size. Kidneys - normal texture, no hydronephrosis. Pancreas appeared normal.

Oesophagogastroduodenoscopy (OGD): revealed a submucosal mass; no biopsy had been taken on initial inspection.


1) Please make a full list of ALL the patient's problems and make assessments according to diagnostic grouping.

2) What other laboratory study or studies would you consider performing in this patient?

3) What is your top suspected diagnosis for the MAIN problem in this patient and how would you establish the definitive diagnosis?

The answer to this case will be available in the near future. Please send in your responses and get published online. Anonymous replies are welcome too!

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