Clinical Problem Solving Starring: Tavo Heudebert Supporting

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Clinical Problem Solving

• Starring Tavo Heudebert
• Supporting Cast Bob Centor

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Case 1 Back pain

• 50 yo white male
• Type II DM
• Hypertension
• Increasing back pain (3 weeks), polydipsia and
  polyuria

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HPI

• 3 weeks ago PCP gave pain meds
• Pain worsened
• Fever, muscle aches and joint arthralgias
• Community ER 1 week ago
• Prednisone
• No improvement

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PMH

• Multiple disc herniations on MRI in past

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Meds

• Avandamet
• Lyrica
• Requip
• Cymbalta
• Ultram
• Neurontin

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SH

• Disability for chronic back pain
• 1 ppd
• Previous EtOH abuse
• Denies illicit drugs

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PE

• BP 91/69 P 129 RR 14 T 96.6
• WDWN moderate distress
• Sunken eyes
• Oropharynx is dry
• CV S1, S2 nl no murmurs or gallops
• Lungs clear
• Abd soft non tender
• Back tender over L3 and L4
• Neuro no focal findings

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Labs

• CBC
• WBC 28.2 80 p, 17 b
• Hgb 16, Hct 44
• Plat 50k

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More lab

• TP 5.2 Alb 2.5
• Alk phos 232 T Bili 1.4
• AST 17 ALT 17
• CBM CK 134 Troponin 0.5
• U/A Cloudy, Large glucose and ketones
• Sp gr 1.015
• Blood Large, Nitrate -, Leukocytes Large

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Imaging

• CXR no acute abnormalities

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Hospital day 2

• Urine culture - gt 100,000 MRSA

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Blood culture

• MRSA same organism

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Final diagnosis

• ECHO mild dilation LV with hypokinesis of ant,
  anteroseptal and apical walls
• EF 25
• Large vegetation anterior leaflet mitral valve

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Comments and discussion
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Case 2 Situs Inversus and abd pain

• 20 yo WF
• Recent dx of situs inversus
• Now abdominal pain

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Abdominal pain

• Severe mid-epigastric
• Nausea and vomiting
• Increased by food
• In ER 2 days previously same sx normal CT and
  LUQ ultrasound
• Amylase and lipase slightly increased at that time

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Social history

• College student
• Minimal alcohol
• Occasional marijuana
• 6 small tattoos

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More history

• Symptoms started 6 months ago
• She has stopped eating fatty foods because of sx

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Physical exam

• T 98.2 P 80 R 20 BP 122/75
• Good BS
• LUQ tenderness
• ? Murphys sign
• Otherwise unremarkable

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Labs

• WBC 8.7, H/H 14.4/40.8, plat 244
• Na 138, K 3.4, Cl 29, HCO3 20, BUN 16, Cr 0.7,
  glu 101, Ca 10.1
• Lipase 90

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Diagnostic tests
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Differential diagnosis
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GI consultation

• HIDA scan
• Result
• Gallbladder EF 12

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Denouement

• GI surgery cholecystectomy
• Path
• Chronic cholecystitis

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Comment

• Especially on HIDA ejection fraction

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Case 3 Back pain

• 41 yo WF presents with severe back pain
• Back pain started 2 years ago
• Primary care MD dxed fibromyalgia
• Previous treatment epidural topiramate and oral
  methadone

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More HPI

• Over past 3 months back pain much worse 10/10
• No relieving or exacerbating factors

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Current meds

• Cymbalta 60 mg
• Methadone 2mg total of 5 /day
• Restoril 30 mg
• Promethazine 25 mg q8h
• Esgic plus
• Topiramate 1200 mg bid
• Inderal 40 mg bid
• Valium 5mg tid
• Xanax 1mg tid
• Lasix 40 mg daily
• Goodys powders prn

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Social history

• Disability for back pain
• Stopped smoking 3 wks ago (lost taste for
  cigarettes)
• 40 pack years
• Denies alcohol or illicit drugs

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PE

• T 97.6 P 98 R 22 BP 130/90
• Obese, slurred speech
• ? Icteric sclera
• Dry oropharynx
• Lungs clear
• Cardiac normal
• Spine thoracic tenderness but no point
  tenderness

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Lab Data

• WBC 16k Hgb 15.5 plat 115
• Na 141 K 1.2 Cl 85 HCO3 46 BUN 25 Cr 0.7 glu 147
• Ca 9 Phos 2.3 Mg 1.0
• ABG pH 7.71 pCO2 53 pO2 48

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Liver tests

• Alk phos 324, T.Bili 3.0, D. Bili 1.4
• TP 5.6, alb 3.1, INR 1.1
• AST 347, ALT 928

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More lab

• Cortisol 142
• Urine Cl 44
• Hepatitis profile all negative

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X-rays

• Density RUL
• Thoracic spine T5, T9 compression fractures

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CT chest

• large right hilar mass
• right paratracheal lymphadenopathy

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Denouement

• Small cell carcinoma of lung
• ACTH level 1056 (nl 0-46)

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Comments and discussion