CASE STUDY

Case #3: Multiple problems, no complaints

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A 61-year-old white male presents to practice for a physical examination. His care is transferred from his previous primary care provider. The patient denies any concerns at present. His past medical history includes myocardial infarction and stent placement (age 58), obesity, prediabetes, hypertension, dyslipidemia, benign prostatic hypertrophy, and osteoarthritis.

The patient is currently taking the following medications:
Altace 5 mg 1 po daily
Lipitor 20 mg 1 po daily
Metoprolol 100 mg 1 po daily
Nexium 40 1 po daily
Tylenol 2 tabs po daily

Physical examination (PE) is as follows:
VS: 97.8; Pulse: 66 R: 18; BP: 130/78
BMI: 38
HEENT: normal
Lungs: clear bilaterally
Abdomen: large, no masses
Heart: S1S2; RRR; + S4; no murmurs
PV: DPPT: 2+ bilateral
MS: unremarkable PE except for Heberden's and Bouchard's nodes, hands

Laboratory results are as follows:
CBC: normal
CMP: normal except fasting glucose 181
Alkaline phosphatase: 132; (0 - 122)
LFT's: remainder normal
TSH: 1.78
Lipid: 130/34/66/149
A1C: 7.8%
Microalbumin: 32
Fractionation alkaline phosphatase
ALK: 268 (25 - 160)
Liver: 90 (26 - 86)
Bone: 10 (11 - 68)
Intestine: 0

US Abdomen: Dilated bile duct: no evidence of masses or gallstones
CT: Diffuse lymphadenopathy, inguinal and pelvic region, largest of which measures 2 cm
CT: Thorax: Mediastinal lymphadenopathy

What is the diagnosis? What next steps were taken? Click here to find out

Hearing her pulse, CASE #2
Submitted by W. Lane Edwards, JR., MSN, ARNP, ANP

After reading the case details below, go to the Instant Poll on the home page of APCToday and submit your diagnosis. Check back next month to see if you are right!

A 36-year-old white female presents with complaints of “hearing her pulse” in her ears. No other signs or symptoms are found in the review of systems.

The onset was about 3 weeks ago. The problem is not improving, and not increasing; the sound is usually heard at night more than during the day. However, the patient offers that she is very busy with her 5-year-old, but when she sits down to rest during his nap, she hears it. The sound does not change with position change.

Family history: Uneventful. Her parents are alive and well, with normal issues of aging (76 and 80 years old).

PMH: G — 1, P-1, no complications; T & A as a child without complications

Meds: ASA 81, I po daily; Calcium 500 mg TID, Vit D 1000 iu daily

Social History: The patient is married, lives with her husband and describes a good relationship. They have a 5-year-old son without unusual growth and development issues. She works in the home and home schools her child. Exercise consists of walking daily for 20 min, about 1.2 miles daily/ 6 of 7 days a week as a routine. She is a nonsmoker, and drinks no more than 1 glass of wine weekly, if that. She recalls no dietary changes and reports no recreational drug use or significant stress in life.

Labs: None in last year; prior labs showed no abnormalities of significance

Exam: BP 168/100 Lt; 170/104 Rt upper extremity (last recorded BP 130/66 3 months)
      Heart rate 70, regular; weight 125 lbs; waist 28”, 5’9” tall

Physical: Nothing remarkable, especially for hypertension.

Testing: EKG shows sinus mechanism, rate 72, no AV or intraventricular conduction issues; no ST T changes, no increased voltage in AVL or any suggestion of LVH.

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CHECK YOUR DIAGNOSIS, Case #1
Knee and back pain without apparent cause

A 38-year-old woman presents with a 2-year history of excessive fatigue and pain in both her knees and lower back without obvious cause. She denies any noticeable tick bite or rash. She has seen numerous healthcare professionals and has had extensive workups.

Diagnosis

The patient was diagnosed with Lyme disease even though her initial Lyme titer was negative. A referral to an Infectious Disease specialist was initiated. The patient was treated with antibiotics and began to show improvement within approximately 1 week of antibiotic therapy. Due to the length of her illness and symptomatology, the specialist placed her on an antibiotic x 30 days. At present her symptoms are significantly improved and her quality of life has returned to approximately 90% of what it was previous to infection. This case illustrates the importance of continuing to investigate when a patient presents with continuing symptoms.

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