Ross Parker
Writeup #2
Measey: Dr. Doyle
Source: patient
CC: "I've been extremely weak for the past three weeks."
HPI: PK is an 82 year-old male with past medical history of CLL, paraneoplastic
pemphigus, and HTN who presents to the ED complaining of weakness for 3 weeks. He
says that he can only take 7 or 8 steps before having to sit down and has been dependent
on a wheelchair for mobility. The weakness has been constant for that duration, and
nothing relieves or exacerbates it. Although he admits to shortness of breath with
exertion which "clears up quickly" with rest, he says that this weakness in unrelated to his
shortness of breath. He admits to decreased appetite but says that this has been true for
"many years." He has a history of a systolic heart murmur, although he says that it was
deemed to be benign by a cardiologist. He also had 3 teeth extracted 3 weeks ago, after
which he was put on a 10 day course of amoxicillin. He denies fevers/chills/sweats, chest
pain, abdominal pain, nausea/vomiting, dysuria, and urinary frequency/urgency.
PMH:
CLL - diagnosed 3 years ago
Paraneoplastic pemphigus - secondary to CLL, occurred 3 years ago at time of CLL dx
HTN - diagnosed "many years ago"
+PPD at age 20
PSH:
Bilateral cateract surgery - 1 year ago
Cholecystectomy - 3 years ago
Subtotal thyroidectomy - 20 years ago
Allergies: NKDA
Medications:
prednisone 15 mg daily
cyclophosphamide 25 mg daily
bactrim 1 DS pill 3x/week
lisinopril 2.5 mg daily
lansoprazole 30 mg daily
INH 300 mg daily "since age 20" for +PPD
Vit B6 100 mg daily
MVI
FH:
Two sisters: one died of breast cancer, one died of colon cancer
Father had CAD, died of MI at age 66
SH:
Retired psychiatrist, worked at the Philadelphia VA hospital. First wife died in 1991,
been married to second wife for 12 years. Has a son and a daughter. Smoked cigarettes
briefly as teenager, quit at age 16. Denies any alcohol or illicit drug use.
ROS:
General: as per HPI
HEENT: bilateral hearing aids
Pulm: as per HPI
CV: as per HPI; also admits to "occasional" palpitations
GI: denies abdominal pain, n/v/d; normal bowels/bowel habits
GU: normal as per HPI
Musculoskeletal: can't raise L arm above 90o, says this is 2o to pemphigus
Neuro: normal
Psych: mood "ok," denies depression
Endocrine: normal
Heme: normal
PE:
General: Elderly male with normal body habitus, breathing rapidly and deeply but
speaking in complete sentences, slightly restless, mild distress. Appears stated age. Alert
and oriented x 3.
VS: T 98.1 HR 102 BP 84/42 RR 30
HEENT: PERRLA, EOMI, eyes anicteric with normal conjunctiva, diminished auditory
acuity, poor dentition, MMM
Neck: trachea midline, no JVD, no lymphadenopathy, no carotid bruits
Pulm: lungs clear to auscultation bilaterally
Cor: RRR, normal S1 S2, no audible m/r/g, PMI nondisplaced
GI: abdomen soft, nontender/nondistended, +bowel sounds
GU: Foley catheter, minimal urine output (less than 50 mL) when catheter inserted
Ext: no edema, cyanosis, pulses 2+ radial and pedal
Skin: no rashes, varicose veins on feet and chest
Neuro: mild hand tremors bilaterally; reflexes 2+ patellar, brachioradialis, and biceps
Musculoskeletal: strength 5/5 in all extremities, increased tone in lower extremities
Data:
Panel 7
147
107
44
118
5.0
24
4.2
Calculated GFR: 14.74 by MDRD formula
(BUN/Creat 13/0.8 from 4/05)
CBC
18.2
12.1
37.2
MCV 70.6, RDW 23.9
157
ALT 15
AST 28
Alk Phos 74
T Bili 0.9
Alb 3.6
T Prot 5.3
TSH 1.23
PT 14.3
PTT 24
INR 1.5
Amy 48
Lip 22
UA:
hazy, specific gravity 1.030, pH 5.0
protein 75 mg/dl, glucose 50 mg/dl
RBC 0, WBC 3-5
bacteria moderate, mucus moderate
casts hyaline >10, granular 6-10
EKG: sinus tachycardia
CXR: normal, no infiltrate
Renal u/s: high resistance indices, no hydronephrosis
Summary: 82 year-old male with PMH of CLL, paraneoplastic pemphigus, and HTN
presents with 3 weeks of extreme weakness. Patient is hypotensive, and labs are
significant for elevated WBC and acute renal failure.
Assessment/plan:
1. Hypotension: Patient has blood pressure of 84/42. This is even more significant
considering PMH of HTN, although he has been treated with and ACEi for many years.
Differential diagnosis:
a. Sepsis: Patient meets 3 of 4 criteria for sepsis (HR > 90, RR > 20, WBC >
12000). Patient is afebrile, although he is on long-term corticosteroids which may blunt
the fever response. Patient had minimal urine output (< 50 mL) when Foley catheter was
inserted and therefore likely has oliguria, which is evidence of organ hypoperfusion. At
this point, source of potential infection is unknown. UTI and bacteremia are most likely.
Endocarditis is possible since patient may have an abnormal valve surface (history of
systolic murmur) and has a route for transient bacteremia (poor dentition/recent dental
extractions).
b. Hypovolemia: Hemorrhage vs. fluid loss. Hemorrhage is unlikely, but GI bleed
is possible. Although patient does not complain of blood per rectum or changes in stool
color, a rectal exam/fecal occult blood test is not unreasonable. Fluid loss would most
likely be from inadequate replacement of insensible losses, as patient denies vomiting or
diarrhea. This is supported by a high normal plasma Na.
c. Cardiogenic: normal EKG and normal cardiac exam makes this unlikely.
Plan: Admit to special care unit (SCU). Aggressive fluid resuscitation to raise
BP. Hold lisinopril. Blood cultures x 2, urine cultures to look for bacteremia/UTI (most
likely sources of potential infection). Consider transthoracic echocardiogram if blood
cultures positive, and possibly even if blood cultures negative (5% of native valve
endocarditis are culture negative). Treat empirically with IV cefepime 2g q 24h (renal
dosing for GFR 11-29) to cover community-acquired organisms. Get manual differential
to check for signs of acute infection, i.e. elevated neutrophils and left shift. Follow
WBC. Watch for sequelae of sepsis including organ failure, thrombocytopenia, and
lactic acidosis.
2. Acute renal failure: Patient has elevated creat of 4.2 (presumed baseline is 0.8). GFR
14.74 by MDRD formula. Oliguria may also be present. Differential diagnosis:
a. Prerenal: BUN/Creat ratio > 10:1 and borderline hyperkalemia suggests a
prerenal etiology. Sepsis is a likely etiology, as it would cause peripheral vasodilation,
decreased systemic BP, and renal hypoperfusion. In addition, patient takes an ACEi,
which not only causes vasodilation but limits the ability of the kidney to respond to
hypoperfusion. Patient is elderly and likely has poor fluid intake, which may contribute
to volume depletion. Patient does not take diuretics. Other causes of prerenal azotemia
(e.g. CHF, acute MI, renal vascular occlusion) are extremely unlikely.
b. Renal
1. Acute tubular necrosis (ATN). Proteinuria and the presence of granular
casts supports diagnoses of ATN. Most likely etiology is ischemia caused by renal
hypoperfusion, as suggested by low BP and potential oliguria; sepsis is likely etiology,
and ACEi use contributes to hypoperfusion and limits renal adaptation as mentioned
above. In addition, patient takes a sulfa drug (Bactrim), which is nephrotoxic and
associated with ATN.
2. Acute interstitial nephritis (AIN): "Classic triad" of fever, skin rash, and
eosiniphilia not present (although it only occurs in a third of cases.) This is less likely
than ATN, although patient recently took amoxicillin and the UA shows WBCs.
3. Acute glomerulonephritis: Effectively ruled out since patient is not
hypertensive, not edemetous, and the UA shows neither dysmorphic RBCs nor RBC
casts.
c. Postrenal: ultrasound does not show obstruction or hydronephrosis, effectively
ruling out postrenal causes.
Plan: Hold lisinopril, bactrim. Aggressive volume repletion to improve renal
perfusion and reduce ischemia. Measure urine Na and Creat and calculate FeNa: < 1%
suggests prerenal azotemia, > 2% suggests renal parenchymal damage, i.e. ATN.
Monitor plasma K and treat hyperkalemia if necessary. Follow plasma Creat to assess
improvement in renal function.
3. Microcytic anemia. Anemia is only mild (12.1) but patient has MCV of 70.6 and
RDW of 23.9. Differential diagnosis:
a. Iron deficiency: Most common cause of microcytic anemia. Increased RDW
consistent with this diagnosis. Etiology is mostly likely decreased intake since patient
complains of chronic loss of appetite.
b. Sideroblasic anemia: Could either be from CLL or from chronic INH use.
Plan: Hold INH. Measure serum ferritin, iron, TIBC to assess for iron deficiency.
Consider iron supplementation if low ferritin, low iron, high TIBC.
4. CLL/Pemphigus: Patient is treated with prednisone/cyclophosphamide. Hold
prednisone and start stress dose steroids, e.g. IV solumedrol. Hold cyclophosphamide.
Follow CBC/diff.
5. Prophylaxis:
lansoprazole 30mg daily for GI/aspiration prophylaxis
heparin 5000 units sc q12h for DVT prophylaxis