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Clinical Pathologic Conference

Baylor College of Medicine

Room M-112 DeBakey Building

December 9, 2004

12:15-1:15 PM

 Case Discussant: Michael J. Bell, M.D.

Pathologist: Gordana Verstovsek, M.D.

Case Preparation: Tapan M. Kadia, M.D.

 

Chief Complaint: Joint pain, diarrhea, weight loss.

History of Present Illness:  

The patient is a 66-year-old Caucasian gentleman with multiple medical problems including HTN, CAD, and anemia who has been followed chronically by both his PCP and rheumatology for “arthritis”.   Patient now presents to his PCP c/o progressively worsening and unrelenting diarrhea for the past 2 months.   The patient describes having several (5-6) moderate to large volume, non-bloody, loose bowel movements per day.   He   describes the stool as ‘watery’, not containing mucous, and not particularly foul-smelling.   The majority of loose bowel movements occur in the morning, often occurring as frequently as every hour.   No one else in the family has had a similar illness and he has no personal, prior history of this diarrhea.   Patient denies any new eating habits or recent travel.   Although there is no obvious association between diarrhea and eating, he has avoided dairy products with no relief in symptoms.   He denies any nausea, vomiting, abdominal pain, constipation, hematochezia, or melena.   The patient hasn’t noticed any fevers, chills, hematuria, dysuria, or obstructive urinary symptoms.   He admits to a decreased appetite,   and has had an unintentional 35 lbs. weight loss over the past 10 months.

 

During the same visit, the patient continues to complain about his chronic joint pain.   The patient describes pain in his shoulders, wrists, hands, and ankles that has been intermittent in nature for 8-10 years.   The pain is described as worse in the morning, with some improvement throughout the day.   He does admit to symptoms consistent with morning stiffness.   Initially, the patient tried self medicating with a combination pill from Mexico (containing Indomethacin, prednisone, APAP) with little relief.   He was referred to rheumatology by his PCP for further w/u.   Although his serologic markers were negative, the patient was felt to have a systemic inflammatory arthritis, with arthralgias, most consistent with a seronegative rheumatoid arthritis.   He has been maintained with methotrexate and prednisone with only mild relief.

 

On further review of symptoms, patient denies any chest pain, palpitations, SOB, DOE, orthopnea, PND, cough or hemoptysis.   He does admit to some chronic fatigue that he attributes to his ‘anemia’.   Pt has had a long standing anemia with normal ferritin.   He has a personal, remote history of ‘an ulcer’.   However, recent (10 months prior) GI evaluation including and EGD and colonoscopy have only revealed few, non bleeding diverticuli and hemorrhoids.   Currently, patient denies any new focal neurologic deficits, visual disturbances, rashes, or jaw pain.   However, 18 months ago, he was admitted to the hospital with an episode of right hemiparesis with associated altered mental status.   The patient was admitted, evaluated by neurology and medicine for cerebrovascular vs. infectious etiology.   At the time, an extensive workup was negative, and the patient’s symptoms spontaneously resolved.  

Past Medical History:  

1. Hypertension

2. CAD (s/p 3 vessel CABG in 4/2004)

3. "Seronegative Rheumatoid Arthritis"

4. Anemia of unknown etioloty (normal ferritin)

5. Personal history of PUD

6. Chronic b/l small pleural effusions vs. pleural thickening since 11/02. Repeated CXR have been stable/unchanged.

 

Family History: No significant family history.  

Social History: Patient formerly worked as an agricultural worker, and then a pipe fitter for Brown & Root.   He was brought up in Kingsville , TX , currently lives in LaPorte, and has never been to Mexico .   He has 5 grown children, and currently lives with his wife and son.   Pt. has not smoked in 42 years.   Denies ETOH use and illicit drug use.

Medications:  

  1. Felodipine 10mg PO QD
  2. FeSO4 325mg PO TID
  3. Folate 1mg PO QD
  4. Furosemide 40mg PO QD
  5. Lisinopril 20mg PO QD
  6. Metoprolol 25mg PO BID
  7. Methotrexate 15mg PO Qweek
  8. MVI PO QD
  9. Omeprazole 20mg PO Q12h
  10. Prednisone 4mg PO QD
  11. Imdur 30mg PO QD

Allergies: No known drug allergies. 

 

Physical Exam: 

Temperature: 99.0 degrees Fahrenheit   

Blood pressure:127/58

Heart rate: 96 beats per minute

Respiratory rate: 20 breaths per minute

Height: 66 inches

Weight:158 lbs

GEN: Thin Caucasian male in NAD, AAOx3; comfortable appearing.

 

HEENT: Pupils were equal, round and reactive to light, extraocular muscles were intact.   Sclera were anicteric.   Mucous membranes were moist.   No oropharyngeal lesions, no exudates.  

 

NECK: The neck was supple with lymphadenopathy and no JVD.   No carotid bruits appreciated.   No thyromegaly, no masses.  

 

HEART: Regular rate and rhythm.   No murmurs, gallops, rubs.   Midline, well healed sternotomy scar.

 

LUNGS: Clear to auscultation bilaterally; no rales, rhonchi, or wheezes.

 

ABDOMEN: Soft, nontender, nondistended, bowel sounds were present.   There was no hepatosplenomegaly.   No rebound or guarding.  

 

EXT: Bilateral 1+ lower extremity edema to mid shin. 2+ pedal pulses bilaterally.   (+)mild inflammation of b/l wrist joints (R>L) with mild pain on passive ROM.   Very slight inflammation/swelling over left 2 nd MCP joint.   Patient is unable to entirely make a closed fist with his right hand due to stiffness.   No deformities or deviation of phalanges. (+)bilateral   ankle swelling with decreased ROM.   Knees without synovitis or effusion, although some limited ROM.   Shoulders with good ROM.

 

BACK: No spinal tenderness or deformity. Full flexion and extension without pain.

 

NEURO: The patient was alert and oriented x three.   Cranial nerves were intact. The DTRs were 2+ bilaterally and symmetrically.   Motor strength was 5/5 in b/l upper and lower extremities.   No sensory deficits elicited.

 

SKIN: No rashes,ecchymoses.

Laboratory Data: See lab flow sheet  

 

STUDIES (Historical):

Hand Films(1/2003) -   Some deformities in the first carpometacarpal joints in both hands more prominence on the left side in keeping with old injury with some post-traumatic arthritis. Some degenerative changes in both wrists are also demonstrated. Otherwise no evidence of recent fracture or dislocation seen in both hands. No evidence of rheumatoid arthritis. Old injury in the distal interphalangeal joint of the right 4th finger cannot be excluded.

 

Knee Films(1/2003) - Right knee: No fracture, dislocation or effusion.   

 

Shoulder Films(1/2003) - Right shoulder: No fracture or dislocation.

 

CXR(1/2004) - heart size is normal.  No acute infiltrate. Coronary artery calcification. Blunting of the costophrenic angles is most likely pleural reaction.  Scarring in the lingula. No hilar or mediastinal abnormality.

 

CT Chest(11/2003) - Bilateral scattered pleuro-parenchymal scarring, right more than left. No pulmonary nodules or atelectasis. Bilateral pleural thickening and tiny right pleural effusions. No mediastinal or hilar adenopathy.

 

Colonoscopy(7/2003) - Diffuse small-mouth diverticula seen in ascending and sigmoid colon. Small external hemorrhoids present. Floor of cecum was not adequately visualized secondary to solid stool. Otherwise normal.

 

EGD(2/2003) – Within normal limits. No mucosal abnormalities.

Hospital Course:   The patient was admitted to a hospital for further workup and management.   A diagnostic procedure was performed.  

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Contact: Donna Herrick (dherrick@bcm.tmc.edu)
URL: http://www.bcm.tmc.edu/medicine/CPC/1104_text.html
(Modified: November 10, 2004/ebl)