Case Studies 1
A 73-year-old white male has been experiencing shortness of breath and left-sided chest pain for the last 24 hours. More recently, he has noted shaking chills and a fever. About 3 days before, he had been drinking alcohol excessively and passed out. When he awoke, he noted vomitus on his shirt. He does have a history of hypertension and coronary artery disease. His physical examination indicated that he was tachypneic and had a fever. His heart rate was 110 per minute. His chest examination demonstrated rhonchi in the lower lateral left chest. Studies Results Routine laboratory work Normal except for elevated WBC equal 18,000 with 88% neutrophils Chest X-ray study, p. 1014 Pulmonary opacity in the left lower lung field. Arterial blood gasses (ABGs), p. 109 pH 7.39 (normal: 7.35-7.45) Pco2 36 mm Hg (normal: 35-45 mm Hg) Po2 79 mm Hg (normal: 80-100 mm Hg) HCO3: 23 mEq/L (normal: 22-26 mEq/L) B-type natriuretic peptide (BNP), p. 367 78 pg/mL (normal: <100) EKG, p. 544 No evidence of ischemic disease Blood cultures, p. 708 Positive for Klebsiella Sputum culture, p. 761 Positive for Klebsiella AST, ALT, LDH, alk phos, p. 47 All mildly elevated liver enzymes
Diagnostic Analysis The cause of shortness of breath in this older adult male could be myocardial ischemia, congestive heart failure, pneumonia, or pulmonary embolism. His history of having vomited while unconscious raises the suspicion of aspiration pneumonia. His high WBC and the fever are more compatible with infection. His normal BNP excludes the possibility of congestive heart failure. His chest X-ray demonstrates classic aspiration pneumonia. Critical Thinking Questions
- What are some other tests that could help delineate the cause of shortness of breath? 2. To what antibiotic is Klebsiella commonly sensitive? 3. Should antibiotics be provided empirically upon the initial visit or should antibiotics be withheld until culture and sensitivity reports are available? 4. What are the potential social problems associated with this man’s care and future discharge? 5. What do the abnormal liver enzymes tell you about his alcohol use?
Addison’s Disease
Case Studies 2
This 32-year-old white professional female was noted to have increasing melanosis affecting her skin and gums. She noted that she had become weaker over the past several weeks. She complained of nausea, occasional vomiting, and anorexia. She experienced a 10-pound weight loss in the last 8 weeks. She complained of a relative recent onset of moderate high-back pain. She has noted constipation but has no other gastrointestinal symptoms. She noted early satiety. Over the last 2 years she has developed Reynaud’s phenomena. Her physical exam reveals a thin woman with a dark tan (she recently returned from a vacation in the Caribbean). She weighed 90 lbs. and was 5’2″ tall. She had very little axillary hair but had all normal primary and secondary sexual characteristics. There was evidence of a melanotic gum line around her teeth. The creases of her hands were hypermelanotic. The remaining physical examination was normal.
Studies Results CBC, Normal Chemical profile Normal except: Na = 129 (normal: 136-145 mEq/L) K = 5.1 (normal: 3.5-5 mEq/L)
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EGD Mild gastritis Gastric Emptying Delayed gastric emptying CT Scan Abdomen Adrenal glands not visible CT Scan of the Brain No pituitary tumor Cortisol 8 AM 2 mcg/dL (normal: 5-23 mcg/dL) ACTH 8 AM 3,200 pg./mL (normal: <80 pg/mL) Aldosterone 10 ng/dL (normal: 5-30 ng/dL) 21 hydroxylase antibodies 5 Units/mL (normal: < 1 Units/mL) ANA Positive 1:120 (normal: negative at 1:40 dilution)
T4 (Free), p. 497 2.5 ng/dL (normal: 0.8-2.8 ng/dL) TSH, p. 486 4 microUnits/mL (normal: 2-10 microUnits/mL)
Diagnostic Analysis With the low cortisol level, the diagnosis of Addison disease was made. Her ACTH was high, indicating secondary adrenal failure. ACTH has actions comparable to melanocytic-stimulating hormone thus causing hyperpigmentation, and elevated levels of ACTH caused this woman to be very darkly tanned. No pituitary tumor was found indicating that this was primary adrenal failure. Her elevated ANA and hydroxylase antibodies indicated that she had an autoimmune cause of her Addison’s disease. The small or absent adrenal glands noted on CT scan corroborated autoimmune destruction of her adrenal glands. Although one of her main presenting symptoms was upper GI dysfunction, no pathology, such as peptic disease, was found. Her reduced gastric transit was caused by her Addison disease.
Critical Thinking Questions 1. Of all the tests this young woman had, which single test would be easiest, most diagnostic, and would have explained her entire symptom complex? 2. What are some of the other adrenal function tests that could have been performed to assist in the diagnosis of this woman’s adrenal failure?
- What is the difference between primary and secondary Addison disease, and how can the two be separated? 4. Why was this woman’s sodium low and her potassium elevated?
Sample Solution
