Grand Rounds 4/1/13
The internist as diagnostician – Clinical Pearls from Four Cases
1.
2.
3.
4.
Pituitary tumor
Myasthenia gravis
Rheumatoid arthritis
Genetics of hemochromatosis
Learning Objectives:
Understand the important role of the internist as diagnostician.
Recognize common symptoms which may represent uncommon diseases
Appreciate that certain genetic tests may be useful in the primary care setting.
Recognize symptoms of pituitary tumors
2/15
Night sweat, hot flashes, and back pain for one month. Nausea improved. White nipple discharge for
several months. Normal breast exam
Fsh 0.7 (1.5- __)
LH <.1
HCG –
Progestoerone <.2
Estrodiol<10
Testosterone<12
DHEA 28 – nl
Prolactin -47.2 (2.8-29.2)
PMH: TBI secondary to skull fx in hs dropped while cheerleading
Chicken pox
F A&w
M – kidney problems
Sister – 26 a& w
MRI- sellar and suprasellar mass enhancing intensely with gadoliminum.3.2 x 1.7 x 2.1 with waist at
sellar diaphragm elevating optic chiasm
Labs 4/10
FHS 7.3
LH 2.8
PRL 12.8
TSH 1.61
Prog .3
Estradiol <20
Testosterone 7
12/12
Abdom discomfort, nausea/vomiting since 8/22. Most days. Unimproved by ranitidine. Vomiting 1-2
times each morning. No improvement with stopping OCP or using acidiphilus. Nl BMs, apetite. 15
pound weight loss. Mild abdom discomfort with eating larger meals. Vomitus generally clear to yellow.
Infrequently blood tinged. No history of eating disorder. Denied other symptoms suggesting eating
disorder. Unrelated to type of food. Denied any chemical exposures. Denied anxiety. Transferring back
to ETSU due to symptoms.
p-83
BP 102/68
BMI 22 Wt 105
Gen – well developed,normal
HEENT - nl
Ht – nl
Lungs –nl
Abd – nl
Neuro – nl
MS – nl
Psych – nl
Lymph – nl
TSH, HCG, Abd u/S UGI, CBc, CMP
Metoclopramide
UGI – mod reflux to upper esophagus
u/s - 2 mm gb polyp, ? left renal stone
CBC – nl
CMP – nl
TSH – nl
HCG 2wks later – no response to metoclopramide but responded well to Phenergan once per day.
Trial of omeprazole
Denied alcohol tobacco or drugs
10/12
AM nausea most days, within 2 hrs of awakening and before eating. Stopped OCP but symptoms
persisted. No other GI sx. Felt to be GERD and place on ranitidine.
7/12
19yo GO started on oral contraceptive 4/11 to regulate irregular menses.
Started on LoEstrin which initially helped and then began to have breakthrough bleeding. Stress related
to starting college at UT and boyfriend being in Tri-Cities area. Tired on higher dose estrogen pill.
4/11
17 yo GO.
Amenorhea for 1.5 yrs after having periods. Advised that likely due to PCOS sarted on LoEstrin Was on
OCP for 4-5 months and had menses regularly during that time. Stopped for unclear reasons
Menarche age 13. Had regular periods for two years then abruptly stopped at age 15. Reportedly had
hormone levels checked and normal. (LH, FSH, prolactin, estradiol, estrogen). Pelvic ultrasound all
normal.
Colnsiderd PCOS anovulatory cycles.
No STI. Not sexually active. Complete ROS in 4/11 negative.
September
OA
RA
67 yo m
13 yr history of episodes of intermittent joint pain, bilateral . Shoulders elbows wrists ankles, Freq one
per month. No obvious precipitants. Worse over 6 months. WBC 4.1, plt 91. RA 25 (<20) ANA 1:40,
Lyme neg, CMP, TSH, uric acid normal. Redness, warmth, and swelling increased to 1-2 /wk.
PMH: CAD, lipid
Nonsmoker, alcohol 1/day. Attorney
Exam initlal nl except wrists warm and should crepitius. – nodes, ht lung abd
Iniital impression intermittene inflammatory polyarthritis with borderlin post ANA & RA with
leukopenian dthrombpcytopenei. Melox
CRP 7.7 (<5)
ESR 16
RA 14 (<10)
WBC 2.8 (53% lymp, 30% polys, 17% mono
HGB 15.3 (MCV 87)
Plt 96
ANA 57 (nl)
Symptoms completely controlled with meloxicam. New adenopathy neck – squamous cell of undefined
primary. Surg Rad biologic tx, CT abd splenomeg
8 mos after initial presentation. Hand swelling. RA 17, ESR 28,
3 wk hx hands increased swelling
Spleen 14 x 14 x 6.5
Felty’s syndrome
Infrequent but severe form of RA – RA, splenomegaly, neutropenia
Usually RA appears 10 yrs beofroe nurtorpenia recognized
Infrequently neutropenia and splenomegaly before or at onset of RA sx
Women 60-80%, onset 30s-40s. RA usually severe
More frequejnt and sever extraarticular manifestaitons
DDX
RA
OA
Psoriatic
Crystalline
Psoriatic
1987 American College of Rheumatology (formerly American
Rheumatism Association) revised classification criteria for rheumatoid
arthritis
Criterion
Description
Morning stiffness
Morning stiffness in and around the joints, lasting at least one hour before maximal
improvement.
Arthritis of 3 or
more joint areas
At least 3 joint areas (out of 14 possible areas; right or left PIP, MCP, wrist, elbow, knee,
ankle, MTP joints) simultaneously have had soft- tissue swelling or fluid (not bony
overgrowth alone) as observed by a physician.
Arthritis of hand
joints
At least one area swollen (as defined above) in a wrist, MCP, or PIP joint.
Symmetric arthritis
Simultaneous involvement of the same joint areas (as defined above) on both sides of the
body (bilateral involvement of PIPs, MCPs, or MTPs, without absolute symmetry is
acceptable).
Rheumatoid
nodules
Subcutaneous nodules over bony prominences or extensor surfaces, or in juxta-articular
regions as observed by a physician.
Serum rheumatoid
factor
Demonstration of abnormal amounts of serum rheumatoid factor by any method for which
the result has been positive in less than 5 percent of normal control subjects.
Radiographic
changes
Radiographic changes typical of rheumatoid arthritis on posteroanterior hand or wrist
radiographs, which must include erosions or unequivocal bony decalcification localised in, or
most marked adjacent to, the involved joints (osteoarthritis changes alone do not qualify).
Note: For classification purposes, a patient has RA if at least four of these criteria are
satisfied (the first four must have been present for at least six weeks).
Nails
Myasthenia
65 yo m
2 mo his difficulty with speech slurring. Dysarthrai with eating. Difficulty swallowing. Sx cleared with
stopping. No diplopia, drooping of eyelids. No weakness of extrem. No pain numbness tingling. No
hoarseness, odynophagia, tong swelling. Ach Ab pos. CT chest - no thymus seen.
Mestinon 30 tid plus azathio 50 qid.
Exam tongue weakness with speaking or chewing.
SCC well diff forehead
OSA
Spinal stenosis 2 to OA and DJD
Myasthen
HTN
DM
MO
Venous insuff
Tob never
Wine 6/wk
AZAthioprine 50 mg tid
Mestinon 60 qid
Slurred speech
Dysrthria
Difficulty chewing