Monday, 9 March 2009

A Case For March 09

Dear Bloggers

Sorry that there was no February case. I hope that the March case makes up for it. I thank Dr E. for providing this excellent case and for anonymizing it in advance.

This 34 year old lady presented to an outpatient clinic in the USA with the following symptoms:

  • Headache
  • Dizziness
  • Fatigue
  • Myalgia
  • Non-specific chest discomfort
  • Poor concentration
  • Recurrent Mouth ulcers & odd eating habits
This patient's symptoms started slowly one year before this current consultation.

The headache was intermittent, occurring several times a week. It often occurred upon waking although it would also occur at other times of the day. The pain was described as sharp but not pressing or pulsating. There were no associated visual problems, aura, nausea, vomiting or diarrhoea. The pain scale was 7/10 at its worst. The pain was described as being different to her prior migraines as a teenager. However, when the headache occurred, the patient felt most comfortable sleeping in a dark room. The patient described the pain as being located on the crown (vertex) of her head.

The dizziness was continuous even when lying prone and motionless. However, the symptoms worsened on standing and mobilising. She did not complain of any recent collapses or loss of consciousness. As mentioned above, there was no associated nausea or vomiting. She denied palpitations, dyspnoea, cough, sputum, double vision, hearing disturbance, tinnitus, feelings of ear fullness, ear pain, throat pain, fever and head injury. Despite the dizziness, the patient was able to do most daily activities including driving, cooking, etc. In other words, it did not significantly impair her activity.

On further questioning, the patient admitted that she had heavy periods. Her periods occurred regularly every three weeks, for which the menstrual flow was heavy and her symptoms of headache and dizziness worsened. She denied change in stool colour, haematemeis, malaena, haematochezia. Moreover, she denied overt haematuria. She denied the possibility of pregnancy.

The fatigue was also a continuous feature which affected the patient whereby she would need to sleep in the mid afternoon. Nevertheless, she was able to still look after her three children without problem.

Mylagia affected the patient in several ways. She complained of lower back pain that was refractory to rest. Analgesics helped the pain although she was only prepared to use occasional acetaminophen or ibuprofen. Gastrointestinal side effects from these drugs limited compliance. She had a course of chiropractor and massage therapy which was not effective. She consulted an orthopedic surgeon and a radiograph of her lower spine was taken which proved to be normal.

The muscular pains were in other areas and somewhat non-specific in location. Other areas included the wrists, knees, neck, shoulder etc.

She denied joint pain, stiffness or swelling. She also denied skin rashes or alteration in skin sensation.

The non-specific chest discomfort had been present for several months. It was present particularly on mobilising and heavy lifting. It was central in nature, sharp and 5/10 in severity. There was no radiation of the pain to the jaw, shoulder or arms. She denied interscapular tearing chest pain. The pain was not worsened by breathing and as mentioned, she did not experience breathlessness. The pain was not made better by sitting in the forwards position.

The patient admitted to poor concentration, excessive sleeping tendencies and waking feeling unrefreshed. She denied depressive symptoms, anxiety or suicidal ideation. She denied feeling excessively cold, poor appetite, constipation or neck swelling. There was no history of snoring.

The patient also admitted to recurrent painful mouth ulcers that occurred during her periods. They would take over a week to heal. Moreover, she also developed a somewhat unusual habit of eating ice cubes.

Previous medical history included pyelonephritis 10 years before, iron deficiency anaemia (previously treated) 7 years before, migrainous headaches [as a teenager] and a prior isolated syncopal episode 6 years previously (34 weeks pregnant).

Medications - occasional analgesics. No known drug allergies.

Gynaecological history - as above. She denied any symptoms of abnormal discharge, burning, pain etc. Her last smear test was normal 2 years before.

Obstetric history - She had three children all born through normal vaginal delivery. She never had a termination of pregnancy or spontaneous abortion.

Family history included gastric cancer (father) although her mother had a dysrrhythmia (she was unaware of the type). Her two older brothers were healthy.

Social History - She was a busy house wife looking after her three children. She had poor local support from family or friends. She felt somewhat isolated where she lived. She lived in a third floor apartment which had no working elevator. This exacerbated her symptoms especially when lifting heavy shopping up several flights of stairs. She was otherwise happily married although her husband worked long hours and was not available to help out much in raising their children. She was a non-drinker and non-smoker.

On Examination

General: She look slightly pale but otherwise well. There was no JACCOL. Nails appeared normal.

HEENT: Within normal limits. No palpable thyroid gland enlargement.

CVS: Warm and well perfused. Pulse 70 per minute and regular. BP lying right arm 120/80, 1 minute standing 118/78, 2 minutes standing 127/85, 3 minutes standing 130/92. JVP was not elevated. Heart sounds - 1 & 2 normal. No third or fourth heart sounds or murmurs. No evidence of leg oedema, varicose veins or DVT.

RESP: Respiratory rate 12 per minute and regular. SpO2 = 98% breathing ambient room air. Chest expansion was limited due to pain. Percussion was bilaterally resonant. Auscultation - normal breath sounds. She was tender on pressing the sternal area.

ABDO: Soft, non-tender, no organomegaly or masses. Bowel sounds present. Rectal examination was normal. No blood or masses noted.

Breast Examination: normal. No masses or axillary lymphadenopathy.

CNS - Pupils equal and reactive to light and accommodation. Visual fields normal. Other CNs within normal limits. Cerebellar signs negative. Dix-Hallpike Test negative.

PNS - Tone: Normal throughout. Power 5/5 throughout. Reflexes - normal throughout. Coordination normal (as above). Sensation within normal limits. Babinski sign negative bilaterally. Rhomberg sign negative.

Musculoskeletal: No distal or proximal joint pain or swelling noted. The epitrochlear region was tender on pressing bilaterally. The shoulder regions were also tender on pressing including the lower back and medial part of the femoral aspect of the knee joints. The wrists were also tender when pressed. The patient had full range of motion and was able to bend over to touch her toes with ease.

Skin examination appeared normal. There was no evidence of bruising.


The biochemistry was normal. Thyroid function was normal. Pregnancy test was negative.
Haemoglobin was 8g/dl and MCV was 77. Ferritin was low. Folate and B12 were within normal limits. Inflammatory markers were normal. White cell count and differential were within normal limits. Coagulation was within normal limits.

CXR was normal. Lumbar spine Xray was normal.

ECG was normal.

Gastroscopy and colonoscopy were both normal.

The patient was commenced on iron sulphate therapy of 200mg three times a day with some improvement in her symptoms of dizziness, mouth ulcers and unusual eating habits after several weeks. The other symptoms persisted despite treatment. After 2 months the iron was stopped because the ferritin was within the normal range, Hb was 13 and the MCV was 98.

However, within a few weeks her symptoms began to worsen again. Her Hb was repeated but it was still within the normal range [12.5g/dl].

Question 1: Please make a full problem list.

Question 2: What is your differential diagnosis given the thorough history and physical examination plus basic tests?

Question 3: What additional test are required?

Question 4: What is your leading diagnosis?

Question 5: What is your treatment plan?

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