CPC #1: Tuesday, September 24, 2002
Hurd Hall, The Johns Hopkins Hospital
12:00 Noon

Chief Complaint:
A 59 year old female with lethargy, fatigue, nausea, and vomiting.

History of Present Illness:
The patient is a 59-year-old Caucasian female with 2 day history of fatigue, nausea and vomiting. Ten days ago she felt as if she was developing an URI but her symptoms improved over 3 days. Over the past two days she has developed increasing malaise, dyspnea on exertion to the point where she has difficulty around her house. One day prior to admission she began having severe nausea and vomiting despite not taking any food. There has been no abdominal pain, hematemesis, melena, change in bowel habits. Her husband also reports that she has said that she is dizzy even in bed. He notes that she has been lethargic over the past day, often unable to be aroused and mildly disoriented. She has not had any documented fever, but reports feeling hot. She also developed a red rash around her ankles over the past few days. There is no past history of GI, pulmonary, cardiac, or CNS disease.

Review of Systems:
There is no chest pain or pressure, no dyspnea or cough. She denies any headache, visual changes, or numbness and tingling. No significant weight loss is reported. The patient does relate some mild epigastric pain, but denies any bloody or tarry stools. Her husband has noticed that she has used the bathroom less over the past day.

Past Medical History:
Mild poliomyelitis (1951); Rh-positive hemolytic anemia of newborn requiring exchange (1963); Guillain-Barre syndrome resolving post-plasmapheresis (1993)

Past Surgical history:
Status post hysterectomy

Social History:
No recent travel, denies alcohol and tobacco use.

Family History:
No family history of CNS, GI, pulmonary, cardiac, or hematologic diseases.

Allergies
NKDA

Physical Exam:
The patient is well-developed, well-nourished female, and appears lethargic. Vital signs reveal a BP= 130/85, HR=95, RR= 16, T= 99.6 C. External examination does not reveal any bruising, but there are petechiae over the ankles bilaterally. No lymphadenopathy is noted. No oral ulcers are identified. Lungs are clear bilaterally. No murmurs, rubs, or gallops on cardiac examination. Abdominal examination reveals mild epigastric tenderness, but no masses or organomegaly. Neurologic exam is nonfocal but she has a short attention span due to lethargy and was able to recall 1/3 objects at 5 minutes.

Laboratory values:
Sodium 138 mEq/L, Potassium 4.1 mEq/L, Chloride 104 mEq/L, Bicarb 23 mEq/L, BUN 52 mg/dL, Creatinine 2.8 mg/dL, Glucose 135 mg/dL

CBC
WBC 8490 cells/mm3
Hgb 9.2 g/dL Hematocrit 26.4% MCV 86 fL
Platelet count: 11,000 cells/mm3
(Please see Images 1 and 2 below)

Image 1

Image 2

APTT 25.4 seconds, PT 12.1 seconds (INR 1.0)

AST 51 IU/L ALT 21 IU/L LDH 1622 IU/L CK 283 IU/L (MB fraction 20 mcg/L)

Haptoglobin < 6 mg/dL
Fibrinogen 349 mg/dL
Fibrin degradation products: Positive at 1:10 (20-39 mg/L)

What is your favored diagnosis?

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