CASE STUDY

Case # 5 Fever of unknown origin

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A 74-year-old white male presents to the emergency room (ER) on Monday with persistent fevers, lower and upper extremity weakness, and hematuria. The patient states that he just spent a week at Montauk, on the Long Island shore. On returning home Saturday morning, he developed a fever of 1010 F that lasted for a few hours. His temperature returned to normal then rose again 3 more times into Monday morning. He experienced lower and upper extremity weakness starting on Sunday, one day after the fevers began. Sunday evening he noticed 5-6 drops of blood in his urine, which prompted him to seek medical attention. The fever is accompanied by chills and a frontal headache described as a sharp pain; there is no photophobia, slurring of words, nausea, vomiting, abdominal pain, dizziness, syncope, cough, palpitations, chest pain, or shortness of breath. The upper and lower extremity weakness is not associated with numbness, tingling, pain or throbbing sensation.

The patient describes walking along paved streets but did not hike in the woods. He does not remember getting any insect or animal bites.

Physical Examination: The patient appears in no acute distress, is alert and oriented to person, place, and time.

Vitals: Temp 101 deg F BP: 127/83 HR: 78 O2 Sat 97% Room Air

Skin: Jaundice; with light macular erythematous rash over body

HEENT: Normal atraumatic, EOMI, PERRL, no oral lesions, exudate

Neck: Supple, no JVD, carotid bruits

Respirations: Clear to auscultation and percussion

CV: S1 S2 RRR no murmurs, S3 or S4

Extremities: No edema

GI: Positive BS, mild diffuse tenderness on palpation; no rebound, guarding, HSM

Rectal: Negative blood, no masses

Neuro: CN II - XII intact, Muscular strength - 5/5 RUE, 4/5 LUE, positive light touch and pain sensation throughout all dermatomes

Laboratory results
H/H: 10.9/32.7
Platelets: 62
WBC: 3.19
WBC/ DIFF: Increase in monocytes and basophils
LDH: 224; ESR: 24
Alk. Phos: 244
Hepatitis A, B, C: AB negative, antigen for B negative
Blood Cultures - Negative
Urine Culture - Negative
Rickettsia: Negative
West Nile Virus/ Lyme: Negative
Erchliosis: Negative
Thick Peripheral Smear: Positive
PCR: Positive

Differential Diagnosis
Meningitis; Babesiosis; Ehrilichiosis; Borrelia: Malaria; Chagas Disease.

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Case #4: Nightly fevers and weight loss
Submitted by Aubrey Corrigan, PA-S

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An 86-year-old white male presents to his primary care clinician complaining of fever at night, chills, and weight loss for the past week. He denies having any other symptoms such as pain, nausea, vomiting, or diarrhea. His past medical history includes hypothyroidism, coronary artery disease, hypercholesterolemia, GERD, dementia and osteoarthritis. He has had a pacemaker implanted and multiple basal cell carcinomas removed.

The patient is currently taking the following medications:
Levothyroxine 100 micrograms PO daily
ASA 81mg PO daily
Rabeprazole 20 mg PO daily
Metoprolol ER 25mg PO daily
KCl 10 mEq PO BID
Naproxen 375 mg PO BID

Physical examination (PE) is as follows:
The patient appeared extremely pale and had positive tremors in both upper and lower extremities bilaterally and his chin was chattering severely.
Vital Signs: BP 117/62 HR 120 RR 20 Temp 99.1
CV: S1 S2, no murmurs appreciated. Rate was tachycardic and rapid at 120bpm
Lungs: Clear to auscultation bilaterally. No wheezes, rhonchi or rales
Abdomen: Soft, non-tender, non-distended, positive bowel sounds
Skin: Extremely pale and dry
Oral mucosa and tongue: Pale and dry
Extremities: No calf tenderness bilaterally

Differential Diagnosis: Severe anemia (r/o GI bleed), dehydration, thyroid storm

Case #3: Multiple problems, no complaints
Submitted by Wendy L. Wright, MS, RN, ARNP FNP, FAANP

After reading the case details below, go to the Instant Poll on the home page of APCToday and submit your diagnosis. Or click on the link at the bottom of this page for details about the diagnosis and next steps.

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

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

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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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