MORNING REPORT

HPI CC: 70 y/o w/ shortness of breath x ~1month 70 y/o Caucasian male with a history of HTN, HLD, DM, BPH, ED, and recently diagnosed polyclonal hypergammaglobulinemia presents with shortness of breath, fatigue, and lightheadedness. Symptoms began over month ago with worsening over the past two weeks. He was treated for community acquired pneumonia about a month ago with Azithromycin. He felt a little better while on the ABX but now feels about the same. He endorses shortness of breath, lightheadedness, substernal non-radiating chest pain associated with the shortness of breath, palpitations, feeling easily fatigued, feeling cold, and night sweats. Denies syncopal episodes, subjective fevers, easy bruising, headache, wheeze, cough, sputum production, Abd pain, N/V/Constipation, dysuria, and swelling.

ROS CONSTITUTIONAL: +Fatigue, +lightheadedness No fever, weight loss, change in appetite CENTRAL NERVOUS SYSTEM: No history of vision changes, seizure, weakness ENT: No history of congestion, postnasal drip, sore throat or hearing changes RESPIRATORY: +Shortness of breath, cough off and on, no wheezing CARDIOVASCULAR: +chest pain, + palpitations GASTROINTESTINAL: No nausea, vomiting, abdominal pain, diarrhea, hematochezia, melena GENITOURINARY: No dysuria, urgency, frequency MUSCULOSKELETAL: +knee pain, no arthralgias/myalgias

PMH: HTN, HLD, DM, OA of knee, BPH, ED, and polyclonal hypergammaglobulinemia Medications: Lisinopril, Metformin, Tamsulosin, Finasteride, Sildenafil, ASA, Advil Allergies: Statin intolerance, citric acid Family history: non-contributory Social history: 120 pack year smoking history (3ppd x 40 years, quit 20 years ago, currently smokes cigars), rare ETOH use, denies drug use

PAUSE Differential diagnosis part 1

Physical Exam Vitals: BP:130/53, P:72, T:97.2 F RR: 20 BMI: 32.5 General: Pleasant, alert and oriented, appears stated age, comfortable, seated in chair in NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus, no rhinorrhea, MMM, no erythema or exudates, conjunctival pallor Cardiovascular: Normal Rate, Regular Rhythm, systolic murmur Lungs/Respiratory: No respiratory distress, speaking full sentences, CTAB, no wheezes/rales/rhonchi Abdominal/GI: Normoactive bowel sounds, soft, NTTP, nondistended, no rigidity or guarding, no rebound tenderness, no palpable HSM Extremities: No edema, clubbing, or cyanosis Skin: Warm, dry, no rashes, pallor of nail beds and palms Neuro: Speech intact, no slurring, no aphasia, no involuntary movements or tremors no facial drooping, moves all extremities against gravity

PAUSE Differential diagnosis part 2 Audience requests labs/imaging

Laboratory and Imaging Glucose: 135 H BUN: 28 H Cr. 1.02, Na: 140 K: 4.4 Cl: 111 CO2: 21 Apk Phos: 43 AST: 21 ALT: 16 T. bili: 1.6 H LDH: 204 Haptoglobin: <15  L Retic: 15.88  H WBC: 6.2 RBC: 1.77 L HGB: 6.2 L* HCT: 19.4 L MCV: 109.1 H MCH: 35.0 H MCHC: 32.1 L RDW: 17.0 H PLT: 122 L MPV: 9.3 SEGS: 59.0 LYMPHS: 20.0 MONOCYTES: 10.0 EOSINO: 6.0 BASO: 3.0 H META: 2.0 H SEGS: 59.0  LYMPHS: 20.0  MONOCYTES: 10.0  EOSINO: 6.0  BASO: 3.0  H META: 2.0  H LYMPHOCYTE %: 16.9  L NEUTROPHIL %: 63.3  MONOCYTE %: 13.4  H EOSINOPHIL %: 4.2  BASOPHIL %: 2.2  H

PAUSE Differential diagnosis part 3 Audience votes on diagnosis

Autoimmune Hemolytic Anemia

Presentation Anemia, fatigue, dyspnea, jaundice, splenomegaly Associated with autoimmune conditions (SLE, Ulcerative Colitis) Strong association with CLL  Can be secondary to drugs—extensive list including NSAIDs and common antibiotics

Diagnosis Anemia, Reticulocytosis, positive Coombs test (DAT) Infographic from Medscape

Treatment Transfusion Steroids—first line Rituximab Splenectomy IVIG/Danazol, cyclophosphamide Also: Folate supplementation

References Packman, C. H. (2015). The clinical pictures of autoimmune hemolytic anemia. Transfusion medicine and hemotherapy, 42(5), 317-324. Zanella, A., & Barcellini, W. (2014). Treatment of autoimmune hemolytic anemias. Haematologica, 99(10), 1547-1554.