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8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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A 60-Year-Old Woman With
Fever, Cough and Low Back Pain
± Chapter 8
Based upon: LABORATORY MEDICINE CASEBOOK.
An introduction to clinical reasoning
Jana Raskova, MDProfessor of Pathology & Laboratory Medicine
Stephen Shea, MDProfessor of Pathology & Laboratory MedicineFrederick Skvara, MD Associate Professor of Pathology & Laboratory Medicine
Nagy Mikhail, MD Assistant Professor of Pathology & Laboratory Medicine
UMDNJ-Robert Wood Johnson Medical School Piscataway, NJ
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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History and Physical Exam
A 60 y.o.
Chief complaing: fever and pr oductive cough f or appr oximatelytwo months
Fatigue and low back pain Physical Exam
Aler t , oriented
BP: 120/90
HR: 90 bpm; RR: 23
Temp. 102.2 oF Bilater al r ales
Rest of exam - unremar kable
EGM2
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Slide 2
EGM2 What is the significance of bilateral rales?Eugene G. Martin, 8/21 /2003
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Differential diagnosis?
Tests?
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Radiology
Normal Flat Plate Patient ± On AdmissionBilateral infiltrates
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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CBC
Patient Normal
WBC 12.0 X 103/uL (3.3-11.0)
Neut 76 % (44-88)
Band 12 % (0-10)
Lymph 8% (12-43)
Mono 2% (2-11)
Eos 1% (0-5)
Baso 1% (0-2)
Nucleated RBC 5% (0)
RBC 3.1 X 106/uL (3.9-5.0)
Reticulocytes 1.1% (0.5-1.5)
Hgb 8.5 g/dL (11.6-15.6)
HCT 25.6 % (37.2-50.4)
MCV 82.6 fL (79-99.0)
MCH 27.5 pg (26.0-32.6)
MCHC 32.2 g/dL (31.0-36.0)
Plts 188 thousands/uL (130-400)
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Is this a Shift to the Left? Includes:
Unilobed and two lobednucleus predominate
Seen in: Acute infection
Metaboloc acidosis
Necrosis : myocardialinfarct. malignant tumors
Blood disease:
hemolytic crises,
severe blood loss
chronic granulocyticleukemia,
Band cell
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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CHEMISTRYTest Patient Normal
Glucose 97 mg/dL (65-110)
Creatinine 1.5 mg/dL (0.7-1.4)
BUN 28 mg/dL (7-24)
Uric Acid 7 mg/dL (3.0-8.5)Cholesterol 200 mg/dL (150-240)
Calcium 11.4 mg/dL (8.5-10.5)
Protein 9.8 g/dL (6-8)
Albumin 3.2 g/dL (3.7-5.0)
LDH 265 (100-225)
Alk. Phos. 190 U/L (30-120)
AST 30 U/L (0-55)
GGTP 40 U/L (0-50)
Bilirubin/Bil. Direct 0.4 mg/dL/(.13 mg/dL) (0.0-1.5)/(.02-18)
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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ElectrolytesTest Patient Normal
Na 137 mEq/L (134-143)
K 3.5 mEq/L (3.5-4.9)
Cl 99 mEq/L (95-108)
tCO2 25 mEq/L (21-32)
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Culture results Gram positive cocci
in pairs and chains
Consistent with:Streptococcus
pneumoniae
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Two weeks later
Fever gone, chest clear
Back pain worse
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Differential diagnosis?
Tests?
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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HEMATOLOGY ± 2 weeks later
Patient Normal
WBC 3.4 X 103/uL (3.3-11.0)
Neut 9 % (44-88)
Lymph 27% (12-43)
Mono 4% (2-11)
Eos 0% (0-5)
Baso 0% (0-2)
RBC 3.2 X 106/uL (3.9-5.0)
Reticulocytes 1.% (0.5-1.5)
Hgb 8.6 g/dL (11.6-15.6)
HCT 26.1 % (37.2-50.4)
MCV 81.5 fL (79-99.0)
MCH 26.8 pg (26.0-32.6)
MCHC 32.9 g/dL (31.0-36.0)
Plts 110 thousands/uL (130-400)
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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CHEMISTRY ± 2 Weeks later Test Patient Normal
Glucose 90 mg/dL (65-110)
Creatinine 1.9 mg/dL (0.7-1.4)
BUN 29 mg/dL (7-24)
Uric Acid 9 mg/dL (3.0-8.5)
Cholesterol 199 mg/dL (150-240)
Calcium 12 mg/dL (8.5-10.5)
Protein 10.9 g/dL (6-8)
Albumin 3.7 g/dL (3.7-5.0)
LDH 270 U/L (100-225)
Alk. Phos. 210 U/L (30-120)
AST 50 U/L (0-55)
GGTP 35 U/L (0-50)
Bilirubin/Bil. Direct 0.7 mg/dL/(.11 mg/dL) (0.0-1.5)/(.02-18)
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UrinalysisTest Patient Normal
pH 6 (5.0-7.5)
Protein 3+ (Neg)
Glucose Neg (Neg)
Ketone Neg (Neg)
Occult blood Neg (Neg)
Color Yellow (Yellow)
Clarity Clear (Clear)
Sp. Grav. 1.050 (1.010-1.055)
WBC 3/HPF (0-5)
RBC 1/HPF (0-2)
Cast Hyalin (Neg)
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Peripheral Blood Smear
PatientNormal
RouleauxNormochromic,
normocytic
anemia
8/3/2019 8 a 60 Year Old Woman With Fever Cough and Low Back Pain - Cadoff 2007
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Skull x-rays
Randomly distributed, rounded, punched out lytic lesionsthroughout the skull. Multiple myeloma could also resemblemetastatic breast carcinoma. Treated breast carcinoma,however, often appears sclerotic rather than lytic.
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Serum Protein Electrophoresis Note sharp peak in
the gamma region
indicative of amonoclonal protein
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Serum Immunoelectrophoresis
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Bone Biopsy Bone biopsy
representing morethan 90 percent
replacement of normalmarrow with plasmacells.
Definitive diagnosisrequires > 10 to 15percent plasma cell
involvement of thebone marrow.
http://www.aafp.org/afp/990401ap/1885.html