Name: Mrs. JB
Medical Record #: N24669 Prepared by: KF
Date of Birth: 12/12/1942
Date of Presentation: April 17, 2005, 9:16pm
History and Physical Conducted: April 18, 2005 1-3am
Patient’s Room: 93
1) Patient and daughter – fair reliability, poor insight
This is a 62 yo white female.
Headache, nausea, vomiting, and diarrhea
HISTORY OF PRESENT ILLNESS:
This 62 yo female with a PMH notable for TTP in 1996 who presents with intermittent dizziness, nausea, vomiting, and diarrhea of about 1 week duration. Over this period of time, she has been unable to take in any significant PO intake without vomiting. Her dizziness and lightheadedness are most notable when she stands up, and she has difficulty maintaining her balance due to this. She also notes that has been very tired for this past week, spending approximately 20 hours per day in bed sleeping. She denies pain, headache, fevers, chills, SOB, chest pain, hematemesis, bloody stool, tarry stool, dysuria, and increased bleeding or bruising. The patient is unable to provide further details or further describe her symptoms, and has no idea what might be causing them. She does deny any recent sick contacts, eating any new or abnormal foods, eating any potentially raw meats, and drinking large amounts of tonic water, or anything else that contains quinine.
PAST MEDICAL HISTORY:
1981 – Cesarean section. This was her fourth and final child.
August 1996 – 9 day hospital admission for TTP. Presented with nausea, vomiting, mental status changes, headache, and exertional dyspnea. After ruling out MI, meningitis, hepatic obstruction, renal insufficiency, and collagen vascular disease, the diagnosis of TTP was eventually made. Hospital course included 8 sessions of plasmapheresis, 4 sessions of hemodialysis, high dose IV steroids, and an open kidney biopsy which was complicated by a right pneumothorax.
January 2004 – Dilation and curettage for postmenopausal bleeding. In addition to these events, the patient has current diagnoses of HTN and hypercholesterolemia. She is unsure if she has CHF. Her baseline creatinine, at the time of her elective D&C in January 2004, was 1.7.
REVIEW OF SYSTEMS:
General –She has been excessively somnolent for the past week, sleeping through nearly the entire day. She has been experiencing a headache, lightheadedness, and has had a generalized feeling of dysphoria.
Skin – Patient points out that she has light scratch marks over much of her body where she has been scratching herself. This scratching has been going on for quite some time and is not new in the past week.
HEENT Eyes – The patient has blurry vision associated with her dizziness when she stands up. Otherwise, denies blurry vision, double vision, and any changes in visual acuity.
Nose/throat/mouth/teeth – Denies congestion, rhinorrhea, sore throat, and dental pain.
Respiratory – Denies dyspnea and cough.
Cardiovascular – Denies chest pain, palpitations, and peripheral edema.
Breasts – Denies changes, pain, and masses in breasts.
Gastrointestinal – Patient has diarrhea,
Genitourinary – Denies dysuria, polyuria, and hematuria.
Neurologic – Patient reports that she has had a headache for most of the time over the past week.
Hematopoietic – Denies easy bruising and bleeding. Denies any recent bruises or bleeding.
Skin – Several small, nonpalpable purpura on each upper arm. Two medium brown plaques on back with irregular borders.
Lymph nodes – No periauricular, cervical, supraclavicular, axillary lymphadenectomy.
HEENT – No scleral or sublingual icterus. Oropharynx clear, mucosa moist. Dentition absent.
No clonus, Reflexes – Patellar reflex appropriate bilaterally. Brachioradialis, brachial, and ulnar deep tendon reflexes are all hyperreflexive bilaterally. Babinski positive on right, negative on left.
Thrombotic Thrombocytopenic Purpura (Hemolytic Uremic Syndrome)
Microangiopathic hemolytic anemia – This patient has a hemolytic anemia with a significant shistocytosis. The average shishtocytosis in TTP is 8.45% (with a range of 1% to 18%); her shistocytosis was 5%. Her elevated LDH is also confirmatory of her shistocytosis. On her admission for TTP in 1996, her renal biopsy showed a thrombotic microangioma. Thrombocytopenia, often with purpura – This patient does have a significant thrombocytopenia, with a platelet count of 66. In addition large platelets and clumping of platelets were noted on the peripheral blood smear, but of which are indicative of TTP. Some purpura were noted on physical exam, but they were not particularly prominent.
Acute renal insufficiency that may be associated with anuria – This patient has acute renal failure, with a BUN of 119 and a creatinine of 13.6. She is oliguric (about 30 cc/hour), but not anuric.
Fever – The patient has been afebrile by history.
The main other diagnosis to consider in this clinical picture is diffuse intravascular coagulation (DIC).
Most cases of TTP are idiopathic.
Cancer – Neoplastic processes can precipitate TTP.
Treatment for TTP is plasmapheresis and administration of fresh frozen plasma (FFP).
2) Acute Renal Failure
This patient has acute renal failure. The patient currently has no indications for dialysis, but we will continue to monitor for these indications, such as acidemia, altered mental status, dangerous
electrolyte abnormalities, volume overload, drug overdose, and symptomatic uremia.
This patient is anemic, with a hematocrit of 0.34. This is a hemolytic anemia.
This patient is thrombocytopenic, with a platelet count of 66.
The patient’s diarrhea appears to be fairly mild.
The patient’s antihypertensives are currently being held to ensure adequate renal perfusion during her acute renal insufficiency.
7) Elevated transaminasaes
Her Lipitor will be held while she is in the hospital, because it may be complicating the clinical picture, and hypercholesterolemia is significantly less likely the cause morbidity or mortality while this patient is in the hospital than is her TTP.
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