CASE PRESENTATION

Residents Internal Medicine PGHC

Dr 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 Hg
 RR: 20 /min.
 Temp: 98.8
 O2 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