CASE PRESENTATION

Residents Internal Medicine PGHCDr Sulaiman Aziz Rathore

Dr Danish Ejaz Bhatti

Presenting Complaint

Pain in both hypochondriac regions-- 2 days

History of Present Illness

33 year old male with PMH of asthma in childhood, gluteal tear and disk prolapse one and half month back, presents with history of pain in his lower ribs in hypochondriac region for 2 days. He says the pain started one week

back initially in his right shoulder and then moved to left shoulder and about 2 days back

started in his lower ribs bilaterally.

History of Present Illness

Pain is sharp, 8/10 in intensity, started suddenly while he was lying down, does not radiate,

aggravated by taking deep breath and is not relieved by anything. There is no fever, chills or rigors, cough, chest tightness; although it was difficult for him to breathe because of pain. He also complains of pain in his back, on the sides of spine around mid back, deep seated and is moderate in intensity. Patient is taking shallow

breaths because of pain.

Past Medical History

He hadn't had an asthma attack since age of 15 years. He has a history of torn cartilages in

knee during college more than 10 years back and torn ankle ligament, lumbar sprain at that

time.

Past Medical History

Patient had an admission at PGHC about one and half month back. At that time he came with sever back pain in gluteal

region after lifting heavy weights few days back and later on having sex in the backseat of a car. At that time he had a fever of upto 102 F and had an extensive workup and was diagnosed

Gluteus medius tear vs myositis and lumbar disk prolapse. Although low WBCs (4.6 to 6.7)and negative blood culture he was given Antibiotics (vancomycin and zosyn) for few days for a suspected muscle abcess. Whole body radiolabelled white

blood study showed increased uptake in R posterior pelvis near the right sacroilliac joint, also a smaller focal site superiorly and also in left buttock region medially suggesting infection process.

Past Medical History

His H & H dropped from 12.6/36.9 to 9.4/26.7. FOBT was positive and patient had an endoscopy done showing erosive gastritis. ESR at that admission was 37 and then raised to 98. An MRI of lumbar spine showed degenerative disk disease at

L5-S1 with protrusion of the disk. MRI of pelvis showed inflammatory changes and edema at right side of pelvis,

extending posteriorly and inferiorly from the right sacroiliac region into the right greater sciatic foramen and the right

piriformis and gluteus medius muscle. He was discharged on pain medication with a plan to follow up and a possible CT guided biopsy of gluteus medius. He did not follow up and

spent most of his time at home resting.

Review of symptoms

Patient complains of lost of weight about 20-25 pounds in past 3-4 months. He reports having

low appetite.Pertinent negative findings are No urinary burning or frequency, No skin rashes, No abdominal pain, No other joint complaints.

Allergies and Child hood Illness

Patient had 2 episodes of chicken pox one after the other.

He has history of Hay fever with allergy to Dust, Pollens and Grass.

Social History

Born and raised in Washington DC. Worked as a fiber-optic inspector. H/o prison for 18 months for road rage in 2006-7. Lives with father, had

one year of college. Quit alcohol 3-4 months back, used to be heavy drinker 2-3 years back. Quit smoking 2-3 years

back. Has a pet dog. He was sexually active until one month back.

Home Medication:

Percocet 5/325 mg PO Q 6hrs Protonix 40 mg PO daily Folic Acid 1mg PO daily MV1 one tab PO daily Motrin 800 mg PO Q 8hrs

Examination

On admission vitals were:Pulse: 117 /min.BP: 113/68 mm HgRR: 20 /min.Temp: 98.8O2 sat: 98% on 2 L/min. O2.

Examination

General: Pallor in hands and palpebral conjunctiva. Discomfort with decreased breathing effort.

Respiratory: Decrease expansion of the chest on the basis. Tenderness on palpation on lower ribs B/L at

the exact same spot. Decreased air entry at the basis of lungs B/L.

Examination

CVS: Hyperdynamic heart with ejection flow murmur. S1 + S2 + O

Abdomen: Soft abdomen with no tenderness. No visceromegaly. Normal bowel sounds.

CNS: Normal power, reflexes and sensation

intact.

Examination

Back and Extremities: Slight percussion tenderness of spine in upper

lumbar and lower thoracic region. Negative renal punch Normal straight leg raising Normal leg extensions

Admission Labs:

Hb: 8.4 gm/dl L Hct: 26.2 L WBC: 3.9 L

Granulocytes: 67% Bands: 13% H Nucleated RBCs: 02% H Lymphos: 27.8%

Admission Labs:

Urinalysis: normal findings

Chemistry:

Na: 137 mmol N K: 5.0 mmol N BUN: 8.0 N Creat.: 0.7 N HCO3: 28 N Chloride: 98 mmol N Calcium: 9.6 mg/dl N Glucose: 95 gm/dl N

Admission Labs:

CPK: 38 N

PT/INR: 13.4/1.1 H

PTT: 25

FSP D-Quant: >1000 H

ABGs:

PH: 7.465 H PO2: 63 L PCO2: 37 N HCO3: 26.2 H O2 sat: 93%

Work up after Admission:

Repeat CBC: Hg: 7.2 L Hct: 21.2 L WBC: 4.8 N Plat: 226 N

Work up after Admission

Anemia workup:

MCV: 91

MCH: 31

RDW: 17.2 H

Retic Count: 2.6 H

Abs retic count : 60,000 N

Retic index: 0.9 L

TIBC: 211 L

Iron: 51 L

ESR: 80 H

B12: 554

Folic Acid: 13.5

Work up after admission:

Liver Function Tests: Bilirubin direct: 0.06 N Bilirubin total: 0.20 N Albumin: 3.2 L AST: 19 N ALT: 16 N Alk Phos: 225 H GGT: 112 H

Progress notes:

Patient is in severe pain, not relieved by percocet 5/325 mg Q 4 hours. And still hinders breathing and movement when not controlled.

Pain has ascended and now involves sides of chest from lower ribs up to axillae B/L. And on the back it involves lumbar and thoracic spine.

Patient is constipated and hasn’t passed stool in 2 days.

Complains of sweating in night, drenching sweats and rigors with chills.

Examination has not changed at all.

Work up After Admission:

V/Q scan: low probability for PE Ferritin: 1502 H (1330 previous visit) CRP HS: 27.95 H Hep. Profile: negative RPR: non reactive TSH: 3.72 HIV ELISA: non reactive ANA: negative

Work up After Admission

Electrophoresis: Protein: 5.9 L Alb immuno: 2.96 L Alpha 1: 0.31 Alpha 2: o.92 Beta: 1.02 Gamma: 0.68 No gamma or M spike seen

Radiology:

CXR: normal

Abdominal US: shows enlarged liver measureing 18 cm with fatty infiltration. Normal gall bladder with normal portal vein and CBD diameters. Normal size spleen. Small right Pleural effusion seen.

CT Abdomen with contrast: was reported as normal liver, spleen. Large amount of fecal matter in large bowel. Small B/L pleural effusions are noted.

MRI of Pelvis (as discussed with Dr siddhu): In comparison with previous study, there is decrease in inflammation of gluteal area as noted in previous study. However hematopoietic lesions are seen extensively in pelvic bones and some lumbar vertebrae.

Pending Work up

PPD skin test placed. Immune electrophoresis ordered. Bone scan and SPECT scan are planned. Bone Marrow Biopsy

Differential Diagnosis:

Pulmonary Embolism Costochondritis Pelvic abcess TB spine / Bone marrow TB Multiple Myeloma / Waldenstorms MG Vasculitic syndrome