1. Clinical Pathological Conference Danise Schiliro-Chuang, M.D. Chief Resident Department of Medicine September 14, 2007

2. CHIEF COMPLAINT A 73 year-old Hispanic male presents with recurrent fevers, generalized weakness and myalgia for one month.

3. HISTORY OF PRESENT ILLNESS One month prior to admission: new onset weakness and myalgia Weakness generalized with particular involvement of the lower extremities. Difficulties climbing stairs and rising from a seated position due to weakness and diffuse lower extremity pain Subjective fevers, marked by chills and night sweats Moderate to severe fatigue 7-8 Ib weight loss

4. HISTORY OF PRESENT ILLNESS One day prior to admission: seen by primary care physician, routine labs drawn Day of admission: called to emergency room for a significant decrease in hematocrit from 1 year prior

5. Past Medical History Hypertension Benign prostatic hypertrophy Past Surgical History Inguinal hernia repair 20 years prior to admission Social History Born in Ecuador, in the U.S. for > 30 years, last traveled outside the U.S. to Ecuador >20 years ago. 5 pack-year tobacco history, quit 30 years ago. No alcohol use. No elicit drug use. Lives with wife. Retired painter, construction worker.

6. AllergiesNone Outpatient Medications Fosinopril 10mg daily Amlodipine 5mg daily Doxazosin 2mg at bedtime Ibuprofen prn Tylenol prn Guaifenesin prn

7. Review of Systems Persistent mild dry cough without sputum production or hemoptysis x 3-4 weeks

8. Physical Exam GENERAL Chronic ill-appearing man, appears stated age, no acute distress VITAL SIGNS BP 130/60, HR 82 and regular, RR 18, Temp 102.0, SpO 2 97% room air, Wt 150 Ibs, BMI 24 HEENT Oropharynx clear LYMPH No cervical, axillary or inguinal lymphadenopathy NECK Supple, no jugular venous distension

9. Physical Exam (2) PULMONARY Clear to auscultation bilaterally HEART Normal heart sounds, regular rhythm, no murmurs ABDOMINAL Normal bowel sounds, soft, non-tender, non-distended EXTREMITIES No peripheral edema, 2+ peripheral pulses SKIN No rashes RECTAL Mild symmetric enlarged prostate, no masses, guaiac negative

10. Physical Exam (3) NEURO - Alert and oriented to person, place and time - Gait slow, unsteady; no tremor/spasticity/rigidity - Cranial nerves II-XII intact - Upper extremities: 5/5 motor strength, decreased right wrist flexion, decreased right hand grasp - Lower extremities: hip flexors 3/5 motor strength (right) and 4/5 (left), quadriceps 3/5 motor strength (right) and 4/5 (left) - Sensory: decreased sensation right dorsal foot - Deep Tendon Reflexes: 1+ patellar, 1+ achilles bilaterally; 2+ upper extremities bilaterally - Babinski: flexor response, downgoing toes bilaterally

11. TestRef Range1 Year AgoAdmission HEMATOLOGY Hemoglobin (g/dl)13.5 – 17.514.010.1 Hematocrit (%)41.0 – 53.040.030.6 White-cell count (per mm 3 )4,500 – 11,0006,20010,300 Differential Count (%) Neutrophils40 – 7078 Lymphocytes22 – 446 Monocytes4 – 118 Eosinophils0 – 82 Mean Corpuscular Volume (µm 3 )80 – 10085 Platelet Count (per mm 3 )150,000 – 300,000 210,000411,000 ESR (mm/hr)0 – 1770 PTT (sec)22.1 – 35.131 PT (sec)11.3 – 13.312.1

12. CHEMISTRY TestRef Range1 Year AgoAdmission Sodium (mmol/liter)135 – 145141137 Potassium (mmol/liter)3.4 – 4.84.54.9 Chloride (mmol/liter)100 – 108107108 Carbon dioxide (mmol/liter)23.0 – 31.92722 Urea nitrogen (mg/dl)8 – 251742 Creatinine (mg/dl)0.6 – 1.50.91.4 Calcium (mg/dl)8.5 – 10.58.87.6 Magnesium (mmol/liter)0.7 – 1.01.9 Phosphorus (mmol/liter)2.6 – 4.53.0

13. CHEMISTRY/SEROLOGY TestRef Range1 Year AgoAdmission AST (U/liter)10 – 402075 ALT (U/liter)10 – 5523128 Total Bilirubin (g/dl)0.0 – 1.00.60.5 Direct Bilirubin (g/dl)0.0 – 0.40.1 Total Protein (g/dl)6.0 – 8.37.36.2 Albumin (g/dl)2.6 – 4.14.13.1 Alkaline Phosphatase (U/liter)45 – 11565116 Lactate Dehydrogenase110 - 225211 Antinuclear AntibodyNegative+ (< 1:40) Rheumatoid Factor (IU/ml)< 1579.2 Creatine Phosphokinase45-24543 Aldolase0-77.5

14. Urinalysis: pH 5.5, yellow, clear, negative glucose/bilirubin/ketones/nitrites/leukesterase; 1+ blood; 1+ protein; 0-2 WBC; 5-10 RBC Blood Cultures x 2 – no growth Urine Culture – no growth

15. EKG

24. A Diagnostic Procedure Was Performed