eze8923 Posted February 2, 2011 Share Posted February 2, 2011 This one comes from a VA urgent care setting. I wasn't on the case myself, but was able to follow my fellow classmate who worked it up. Chief Complaint: Flu-like symptoms & weight loss x1 month Subjective: 54 y/o Hispanic male with h/o HTN, hyperlipidemia presents today c/o 10 lbs weight loss over the last 3-4 weeks. Patient reports that he had a full PE at Kaiser 1 month ago and was feeling great. Shortly after that, he started losing his appetite and feeling weak. He reports he felt like his stomach was full and reports eating 600-700 calories/day. He was still taking lots of fluids, mostly water and 7-Up. He reports decreased frequency of bowel movements, which he attributes to decreased food consumption. Patient reports nasal congestion and rhinorrhea followed by a dry cough x5-6 days, as well as right-sided chest pain which is a constant, dull ache rated 4/10 but is a sharp stabbing pain when he coughs and increases to a 5/10. Patient reports all his symptoms suddenly worsened this past Monday when he had increased cough, SOB, nausea, fatigue, and fever up to 101 F. Denies hemoptysis, hematuria, hematochezia. PMH: Meniscus tear, HTN, HLD, presbyopia Allergies: NKDA Medications: atenolol, simvastatin, HCTZ Social Hx: Married, works with children, denies tobacco, EtOH, or other drugs. Review of Systems: Ears - Denies hearing loss, vertigo, tinnitus. Eyes - Denies eye pain, visual loss and vision changes. Throat - Denies sore throat, dysphagia, voice change. GU - Denies dysuria, urgency, hematuria, hesitancy, incontinence, frequency. Musculoskeletal - Denies joint or muscle pains. Skin - Denies lesions, pruritis, rash. Neuro - No syncope, seizures, numbness, tingling, burning, weakness. Physical Exam: Vitals: BP 133/79, HR 78, RR 16, Temp 98.8 F, SpO2 99% on RA, BMI 28.0 General: Patient laying in gurney, appears very uncomfortable but in NAD. Head: NC/AT. Eyes: Fundi benign, nl conjunctiva, EOMI, cornea clear, PERRL. Ears: nl external auditory canal, nl TM, no bulging or retractions. Nose: nl mucosa and septum. Throat: No erythema or exudates. Neck: No masses or bruits, no adenopathy. Lungs: CTAB, no crackles, no wheezing, symmetric rise. Patient coughs with each inspiration and unable to take deep breaths. CV: RRR, no m/r/g. Chest: nl appearing without masses or palpable tenderness, unable to reproduce pain symptoms with palpation. Abdomen: +BS x4, no organmegaly, masses, tenderness. Rectal: Good rectal tone. Negative for occult blood. Neuro: A&O x4. Extremeties: No cyanosis, nl pulses, no edema. I'll leave it at that for now... thoughts? Labs? Discharge? :) Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 Disclaimer: haven't even started the PA school I've been accepted to Social hx of recent travel to developing countries, local visitation to nursing home/jails or other areas where TB is common? Does he have night sweats? What is his family hx? Lab values, interested in white count, liver function, renal function I have always loved the saying of "don't let the skin stand between you and the diagnoses". Not ready to break out the scalpel yet but am curious if there are any shadows or other abnormalities on xray or for that matter, if a CT could be done to look for masses? Link to comment Share on other sites More sharing options...
lzypanda Posted February 2, 2011 Share Posted February 2, 2011 quick glance at his sx I'd be most worried about gastric CA .. I'd probably do cbc, cmp, lipase, CXR, fecal occult blood - f/u with endoscopy, h.pylori for starters Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted February 2, 2011 Administrator Share Posted February 2, 2011 FOB was already reported as negative. I agree, TB looks like something for the diff, but I want a full FHx/SHx before I order labs. I'd want an HIV test on any pt presenting with possible TB, as well... Other things on my DDX include PE, AIDS+something, and cancer--maybe Mesothelioma if he's been exposed. Specific FHx/SHx questions * History of work * History of family/living situation and residence situations * History of association: who does he hang around with for fun? Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 quick glance at his sx I'd be most worried about gastric CA .. I'd probably do cbc, cmp, lipase, CXR, fecal occult blood - f/u with endoscopy, h.pylori for starters I would do barium swallow to look for any obstruction before endoscopy, CT chest and abd/pelvis after CXR. Ask about his occupation (past and present). He's at the age for a screening colonoscopy as well, EKG and cardiac enzymes, D-dimer to r/o PE. Differentials: 1) Pulmonary: pneumonia, pneumothorax, PE, pleurisy 2) Cardiac related 3) GI: hepatitis, gastritis/cancer, bowel obstruction, colitis, cancer Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 Sorry for the multiple posts, don't know what happened there :) Oh, and if there is a high degree of suspicion of TB, he needs to be admitted and quaranteed as TB is a public health issue. Make sure to have him wear a mask and urgent care should have X-ray machine to shoot a couple of film right there and then. PPD test would take 2 days. He cannot be discharged until TB can be ruled out. Definitive test is sputum culture for acid fast staining, even this may take a few days. Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 I am curious to how a PE can attribute to the listed sx? Can anyone draw that connection for me? I am failing to connect those dots. Thanks in advance Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 I am curious to how a PE can attribute to the listed sx? Can anyone draw that connection for me? I am failing to connect those dots. Thanks in advance PE may be lower on the differential list, but still gotta r/o. Dyspnea and chest pain can be caused by PE. When working up a patient, you gotta think of all the possible causes that can be presented with patient's symptoms. Usually a list of 4-5 differentials should be formulated in every case to ensure you don't miss anything. Patients don't read textbooks, so they normally don't present with textbook symptoms, so as clinicians, we're responsible to work them up thoroughly to figure out the problem. Link to comment Share on other sites More sharing options...
Acebecker Posted February 2, 2011 Share Posted February 2, 2011 A couple of other points: With PE you can also get a fever, which this patient has. With dyspnea and pleuritic chest pain you definitely need to consider PE - unfortunately, we're likely going to chase this Dx with some expensive/dangerous tests given the fact that the D-Dimer has common false positives. Unless we find a better explanation for the chest pain, this Pt is in for a CTA. The other thing that can cause R sided chest pain that hasn't been mentioned is cholecystitis. Does this patient have any food idiosyncracies? Does his pain worsen after a high fat meal? At the same time, we have to consider gastric outlet obstruction (given his complaint of feeling full quickly). One thing that can cause both a gastric outlet obstruction and cholecystitis is pancreatic cancer. At any rate, the labs that have been mentioned will point us in a good direction. I would hold off on a CT scan just yet because we are not certain which direction we should go with it - are we looking for a pulmonary cause or a GI cause? This will dictate the type of scan we get. At any rate, lets see where the labs take us. I'm gonna' go with a CBC, CMP, lipase. Any more info? Andrew Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 D-dimer has very high sensitivity so if it's negative, I can r/o PE. If it's positive, I'd do spiral CT. I've listed all the possible tests that can be done for the differentials, but of course, will not be done all at once. Preliminary rests hopefully will point us in the right direction. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted February 2, 2011 Moderator Share Posted February 2, 2011 d-dimer has very high sensitivity so if it's negative, i can r/o pe. just an fyi- d-dimer is sensitive for acute pe but less so for one that has been around for > 1 week. We had a guy with large b/l pe's and a dimer of something like 10 who had sx for 2 weeks..... Link to comment Share on other sites More sharing options...
eze8923 Posted February 2, 2011 Author Share Posted February 2, 2011 no recent travel out of the area reported. unknown family history of chronic illness/malignancy. works with children in a school environment. currently lives with wife at home. likes the outdoors, no "high risk" activities. no exacerbation of symptoms with food/meals. sounds like we've got some good differentials going... here are some of the pertinent labs. WBC 11.4 H RBC 4.23 L HGB 12.5 L HCT 36.7 L MCV 86.8 MCH 29.6 MCHC 34.1 RDW 13.3 PLT 320 NEUT % 84.6 H LYMPH % 7.6 L MONO % 6.2 EOS % 1.0 BASO % 0.6 NEUT # 9.6 H LYMPH # 0.9 L MONO # 0.7 EOS # 0.1 BASO # 0.1 GLUCOSE 95 NA 134 L K 3.4 CL 101 CO2 23 BUN 13 CREAT 1.07 eGFR >60 mL/min CALCIUM 8.4 L ALK PHO 145 H T. BIL 1.0 D. BILI 0.2 AST 50 H ALT 49 ALBUMIN 3.0 L PROTEIN 7.1 AMYLASE 74 we didn't end up going the PE route immediately considering his presentation and current vitals. nonetheless, it's worth considering the PERC (although the patient in this case is >50 y/o) and well's criteria to help risk stratify a bit. calling for a little help here as well - there's another evaluation tool for PE that suddenly escapes me... it's not as widely referenced as the PERC criteria, but i've definitely heard it multiple times. sorry, how frustrating... my EM instructor is spinning in her grave. where shall we go with these?! Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 Always fun to learn a bit...with the history of sx extending for @ 4 weeks I would have assumed a PE would have resolved or gotten worse. Again, pulmonary medicine beyond an EMS stance is not my forte. With a respiratory drive of 16/min and a RA of 99% with clear lung sounds, it seems like he's oxygenating appropriately. His ventilation ability could be debated because of his inability to take deep breaths but it seems he is compensating adequately. (HR being in the 70's)I did not know what a d-dimer test was, googled it, found it to be a measure of enzymes produced by the breakdown of thrombus. Can a d-dimer be positive based on things such as a resolving hematoma? I ask because I am curious if a positive d-dimer 4 weeks after onset of sx would really give the nod to PE/DVT only, or would it just notify of coagulation/dissolution cycle took place somewhere in the body? The VS on exam reveals a normal presentation, afebrile, clear lungs...white count is up a touch, mild anemia, I can't really remember how to break the diff down and the other lab values are lost on me at this point in my lack of training. The story sounds really good for a pulmonary situation such as an increase in the PE situation or pneumonia/infection but the physical exam doesn't support the story...I'm still going with cancer or TB at this point. Steve Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 CXR? EKG? Any sick contact? Given his age, HTN, and hyperlipidemia, I wouldn't ignore his cardiac workup, he has positive cardiac risk factors. I wouldn't jump on PE right away. Pneumonia is actually higher on my list. Steve, he is febrile 101F. FYI, PE can give you normal pulmonary exam. D-dimer is nonspecific, so a positive D-dimer would NOT give you PE, you'd have to do spiral CT to confirm Link to comment Share on other sites More sharing options...
eze8923 Posted February 2, 2011 Author Share Posted February 2, 2011 CXR? EKG? Any sick contact? Given his age, HTN, and hyperlipidemia, I wouldn't ignore his cardiac workup, he has positive cardiac risk factors.I wouldn't jump on PE right away. Pneumonia is actually higher on my list. Steve, he is febrile 101F. FYI, PE can give you normal pulmonary exam. D-dimer is nonspecific, so a positive D-dimer would NOT give you PE, you'd have to do spiral CT to confirm don't have a copy of the EKG, but it's nl. no sick contacts. patient is afebrile at this time (98.8 F on exam) although he reports a fever up to 101 in the last few days. i won't drag this one on, so here's the CXR... thoughts? plan? Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 Sputum culture? Blood culture? I'm tempted to do Xray abd/pelv now. Hepatitis panel? Why not do PPD, wouldn't hurt. Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 Looks like lung cancer all over bilaterally. Consult oncology Link to comment Share on other sites More sharing options...
GREATMDPA Posted February 2, 2011 Share Posted February 2, 2011 Oh...I'd also do a PET scan to check for mets Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 Well that answers the question of what's on the inside...aside his lungs looking like a death sentence to my untrained eye, it appears that his bowels are full..with no food intake in about a month, having that much fecal matter still inside of him...I am going to venture a guess radiological exams of his lower abdomen will reveal more masses. Bummer Link to comment Share on other sites More sharing options...
cobramarty Posted February 2, 2011 Share Posted February 2, 2011 Endocarditis? with septic emboli? sed Rate and blook cultures ordered? Link to comment Share on other sites More sharing options...
fyrelight74 Posted February 2, 2011 Share Posted February 2, 2011 How about a cocci screen? Is he in the valley fever endemic area? Link to comment Share on other sites More sharing options...
Evan Posted February 2, 2011 Share Posted February 2, 2011 Might be putting the cart before the horse here... Get a pulmonary consult for a bronchoscopy. Once the cytology and pathology are back I'd be more inclinded to get the PET and go from there... Making a cancer assumption here could be dangerous as there are just as many infectious and inflammatory conditions that have yet to be considered... Remember: all a PET scan will tell you is that there is SOMETHING there, it doesn't necessarily tell you WHAT it is... Link to comment Share on other sites More sharing options...
bradtPA Posted February 2, 2011 Share Posted February 2, 2011 Might be putting the cart before the horse here... Agreed, I have seen two cases of Wegener's with exactly the same CXR presentation.... Link to comment Share on other sites More sharing options...
cobramarty Posted February 2, 2011 Share Posted February 2, 2011 Has he had recent dental work or colonscopy? 50+yo male with insurance could have had either one recently. Link to comment Share on other sites More sharing options...
Just Steve Posted February 2, 2011 Share Posted February 2, 2011 disclaimer reminder: I can't even call myself a student for another few months...just an accepted enrollee. I enjoy the case studies and by getting to voice my thoughts and receiving feedback, I learn a ton. Thank you for this opportunity and while I don't mind being wrong, I'd love it if you can tell me WHY I am wrong if you don't mind..helps reinforce the learning points. So with the Xray posted, what are our new diff. dx? I have no idea what cancer or TB looks like on films...I assumed cancer would be more dense of a mass and TB being smaller, maybe 2-3 mm spots in the early stages, more concentrated to the more medial lung fields. With the diffuse spread of apparent lesions, it does lend itself to the idea of an inflammatory disease. I googled Wegener's and found http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001192 With the lack of persistent fever (was just one night of fever) and sores, and no mention of blood in the UA, I am not sure about it. I have no idea how much the blood test is to rule it out but it seems to be not that accurate according to the article I found. A biopsy can be used, and perhaps gather some tissue for a cancer rule out as well? With the associated risks of biopsies, would a different radiological exam such as CT be helpful first or is that just reconfirming "something is there", which we already know, and might as well just go in and take a direct look? Link to comment Share on other sites More sharing options...
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