Assignment
Case Study Info:
You are working on the general internal medicine ward service with attending hospitalist, Dr. Mitchell Smithson. He asks you to go evaluate Mr. Jorge Ramirez, a 78-year-old male who was brought in by his daughter after several days of fever, lethargy, and loss of appetite. It sounds to you as if Mr. Ramirez is pretty sick, but from the description, you have no idea why. You realize that you'll need to perform a thorough and comprehensive history and physical exam to look for additional symptoms and localizing signs to help narrow the differential diagnosis.
Maria says, "I am so worried about my father. This isn't like him at all. He's usually always on the go. Now he just sleeps."
You ask:
"How long has this been going on?"
"He hasn't been feeling well for several months, but he's become much worse over the last three or four days. His appetite has been decreasing for a while, but now he won't eat anything, even empanadas, which are his favorite! I can tell he's lost a lot of weight. Today he wouldn't even drink. I tried to wake him up to get him to take some broth, but I don't even think he recognized me! It seemed like he was going to the bathroom to urinate every few minutes for the past couple of days, but in the past day he has not been urinating much at all. He is so weak he can't make it to the bathroom. Today, I noticed he wet himself and it smelled really terrible. He has never had trouble making it to the bathroom before. I wanted to bring him here before, but he kept refusing. He's always hated hospitals and likes to be really independent. I finally dragged him in here today!"
"Has he been having fevers?"
"We don't have a thermometer, but today he felt so hot."
"Is your father having any other symptoms?"
"No, I don't think so. What do you mean, 'other symptoms'"?
You ask Maria more specific questions and find that Mr. Ramirez hasn't had any vomiting, diarrhea, cough, or sweats. He hasn't complained of abdominal pain, chest pain, or rash.
"Ms. Ramirez, who does your father live with?"
"He lives with me."
You learn that Mr. Ramirez has been independent and has taken care of himself without assistance. He has had no problems with memory. He hasn't had exposure to sick contacts or traveled out of the country recently
CHART REVIEW INFO:
• Past Medical History:
Hypertension for 20 years.
Abdominal aortic aneurysm, 3.0 cm on ultrasound four months prior to admission.
Transurethral resection of prostate (TURP) three years ago for benign prostatic hypertrophy (BPH).
Appendectomy age 13.
Osteoarthritis
• Medications:
Hydrochlorothiazide 12.5 mg daily.
Metoprolol XL 50 mg daily.
Aspirin 81 mg daily.
Acetaminophen 650mg prn.
You review Mr. Ramirez's vital signs and see that his pulse is 108 beats per minute and blood pressure is 92/55 mmHg. You are concerned that this blood pressure seems low, since you know he has a history of hypertension. You repeat all the vital signs, making sure the blood pressure cuff is the right size.
You document your findings in your note:
• Physical exam:
• Vital signs:
• Temperature is 35.5 C (95.9 F)
• Pulse is 98 beats/minute
• Respiratory rate is 24 breaths/minute
• Oxygen saturation is 94% on room air
• Blood pressure is 80/52 mmHg
• Weight is 55 kg (122 lbs)
• General: Older adult male lying asleep on the gurney. He arouses with vigorous tactile stimulation (shaking). He seems confused and agitated. He is oriented to name only; he thinks he is in a grocery store and that it is 2004.
• Head, eyes, ears, nose, and throat (HEENT): Normocephalic, atraumatic, EOMI, PERRLA, no JVD, no carotid bruits, neck is supple, negative Kernig's sign without adenopathy. Temporal arteries are both visible and with good pulsations. Lips are cracked, tongue fissured.
• Lungs: Clear to auscultation bilaterally, no dullness to percussion. Moderately tachypneic with fast, shallow breaths, but no accessory muscle use.
• Heart: Tachycardic, regular rhythm. 2/6 SEM at 2nd right intercostal space (ICS) best heard at the apex; no thrill. PMI palpable at 5th left intercostal space in mid-clavicular line.
• Abdomen: Nondistended, Diminished bowel sounds. Soft, non-tender to light and deep palpation. No guarding or rebound. No organomegaly or masses. Pulsatile mass palpable just below the umbilicus.
• Back: Nontender to percussion or palpation, no CVA tenderness.
• Rectal: No external or internal hemorrhoids. Normal rectal tone. Fecal occult blood negative.
• Extremities: Decreased muscle mass. No lesions or edema in lower extremities. Radial and DP pulses are not palpable. Brachial, femoral, and carotids are weak at 1(+). No muscle tenderness to palpation.
• Skin: Warm to touch. No evidence of ulceration or breakdown. Normal palmar pigmentation.
• Neurologic: Sleepy; arouses with vigorous stimuli. Follows simple commands. Strength intact, but poor effort. Sensation grossly intact. DTRs equal, symmetric at 2+. Plantar response bilaterally.
Task
1) What is your list of appropriate differential diagnoses and why?
2) What is the final diagnosis, and what assessment findings serve to support this? Discuss normal versus abnormal findings.
3) Describe the pathophysiology that may lead up to the final diagnoses.
4) What pharmacology treatment would you recommend and why?