Sample Write Up #3

Grade:15/15

Comments: Excellent write-up with organized data presentation and knowledgeable, thoughtful and complete discussion. A bit long.

CHIEF COMPLAINT:“I’ve had a fever for the last eleven days and I feel lousy.”

HISTORY OF PRESENT ILLNESS:  The patient is a 59-year-old Caucasian male with a past medical history of sigmoid diverticulosis who was at his baseline state of health until 3-4 months ago when he started “feeling wiped out”, and “not like (himself)”. More recently, in the last month, he also complained of muscle aches and a general malaise. 11 days ago, he started having fevers between 99 and 101.3 degrees F, which increased to 102 degrees F 3 days ago (measured orally by a digital thermometer). The patient went to his primary care physician two days ago and a number of laboratory tests were performed (which are included in the laboratory section of the write-up). In brief, his tests are significant for a mild AST and ALT elevation. He was advised by his primary care physician that if his temperature increased to greater than 102 degrees F that he should go to the emergency room. The patient states that his temperature has been in the range of 102-103.5 degrees F for the last 24 hours and he decided to come in to the hospital. Patient has been taking acetaminophen intermittently but notes that fevers always recur. Patient complains of night sweats for the last eleven days, but denies chills or rigors. Patient states that three weeks ago he had unprotected intercourse and oral sex with an exotic dancer. He denies any penile discharge, sores, or scrotal pain. He denies previous known STD exposure, homosexual intercourse, IV drug use, or previous blood transfusions. Patient states that he has not had any previous sexual partners in the last twenty years. He has never been tested for HIV or hepatitis and has not been immunized for hepatitis B. The patient denies any upper respiratory symptoms, including cough, sneezing, postnasal drip, ear pain, sinus pressure, or throat pain. He denies shortness of breath or chest pain at rest or with exertion. He denies previous exposure or infection with tuberculosis. He denies painful urination, frequency, urgency, hematuria, back, or flank pain, but notes that he has been suffering from nocturia x5-6 over the last four or five years. He also states that it is difficult to start and stop his stream of urine. Patient denies any nausea or vomiting. For the last year he stated he has suffered from intermittent diarrhea interspersed between periods of constipation. Around twice a week he has 5-6 loose, watery stools that are large in quantity. He notes that after one day of diarrhea, he does not have a bowel movement for 3 or 4 days. Then once again the cycle repeats. He denies blood in his stools, or black tarry stools. He does not complain of greasy or foul smelling stools, nocturnal diarrhea, or fecal incontinence. He does not take any medications to relieve his diarrhea or constipation. He complains of some bloating and abdominal pressure intermittently, but denies any abdominal pain. He denies any sourness in his throat, reflux symptoms, burning epigastric pressure or pain, or recent antibiotics use. He states that for the last year or two he feels satiated after eating relatively small amounts of food. He feels uncomfortable abdominal pressure that is relieved by vomiting, which he induces about once a week. He states that he has wondered whether he is suffering from bulimia. He has not noted any change in appetite or weight during the last year. He does not complain of difficulty or pain when swallowing. Patient does not have a history of PUD, gallstones, pyelonephritis, kidney stones, or pancreatitis. Patient states that one of his co-workers was recently hospitalized for pneumonia, but denies any other sick contacts. Patient has not traveled recently or spent time outdoors. He does not have any pets and has not been exposed to any animals. He has not noticed any rashes, skin changes, joint pain or change in his skin or urine color. Finally, patient denies any headaches, jaw claudication, neck stiffness, vision changes, loss of consciousness, convulsions, numbness or tingling.

PAST MEDICAL HISTORY:

1. Sigmoid diverticulosis. Patient was diagnosed with diverticulosis after a routine flexible sigmoidoscopy in 2000, which was otherwise unremarkable. He does not recall any episodes of diverticulitis. A rectal exam performed by his PCP two days ago showed guaiac positive stools.
2. Hypertension. Patient states that his blood pressure has been in the 130-140/80-90 range for about ten years. He has discussed the pros and cons of anti-hypertensive therapy with his PCP, and has refused medications in the past. Patient states that he has not made any lifestyle modifications to lower his blood pressure.
3. Dyslipidemia. States that his PCP has told him that he has “high cholesterol,” but he has refused medications in the past.
4. Basal cell carcinoma of the left lower eyelid that was diagnosed in 1994 and was completely excised at the time. He states that he has not had any suspicious skin lesions.
5. Erectile dysfunction. The patient’s symptoms have improved with sildenafil, which was originally started in April 2004. Patient is not aware of the etiology of his ED.
6. Previous alcohol abuse. He has not consumed alcohol in the last 24 years.
7. Supraventricular tachycardia. Patient has a documented history of one episode of SVT 6-7 years ago that resolved on its own. He presented to the ED with tachycardia and palpitations and his symptoms resolved without electrical or pharmacological intervention. The patient states that he has not had any other episodes of heart rhythm disturbances and his ECGs have been normal since the one episode of SVT. He does not take any medication for SVT.

Also, denies previous history of CAD, DM, cerebrovascular disease, RA, SLE, or rheumatic heart disease.

PAST SURGICAL HISTORY: Left inguinal hernia repair 4-5 years ago. Patient notes that his recovery was uneventful.

MEDICATIONS: Sildenafil 100 mg 1/2 tablet PRN for impotence. He uses sildenafil about once a week. He has been taking Tylenol 650 mg PO q4 hours PRN for fever during the last eleven days. He takes Tylenol about once or twice a day. He does not take any other medications, including herbals, vitamins, or other over the counter medications.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient is divorced and lives alone. The patient states that he was a heavy drinker (>6 pack of beer per day) for ten to fifteen years. He quit drinking alcohol 24 years ago. He smoked >1 PPD for 45 years and quit 5 years ago. The patient works as a taxi dispatcher at the airport and states that he has not had occupational exposures to dust, volatile substances, fumes, or asbestos. He reports that it is a very stressful job. Patient denies illicit drug use including marijuana, cocaine, LSD, or amphetamines. Patient speaks very fondly of his son and daughter and notes that they are very concerned about his health.

FAMILY HISTORY: Patient’s father was an alcoholic and had a heart attack when he was 62 years old. Patient’s father died in his seventies of unknown causes—“probably because of his drinking.” His mother also died in her seventies and had a “thyroid problem” and “took a pill for it”. He has a 33-year-old son with Charcot-Marie-Tooth disease who is learning disabled, but is living independently and thriving. He also has a 34-year-old daughter who does not have any health problems. He is not aware of a family history of HTN, SLE, RA, inflammatory bowel disease, CVA, lung disease, DM, dyslipidemia, cancers, renal disease, or psychiatric illnesses.

REVIEW OF SYSTEMS:
General: as per HPI.
Skin: Patient denies easy bruising or skin discoloration. Denies dry skin, scaling, eruptions, pruritis, or any changing or new moles.
HEENT: as per HPI, also, denies head injuries or trauma. Wears reading glasses and sees an ophthalmologist every 2-3 years. Denies any history of blurry or double vision. Denies hearing loss, tinnitus, ear infections, ear discharge, or hearing problems. Denies any sores, ulceration, or bleeding from the mouth. States that he visits the dentist yearly. Denies change in voice or hoarseness. Denies epistaxis.
Respiratory: as per HPI.
CV: As per HPI, also denies palpitations, orthopnea, PND, claudication, or pedal edema.
GI: As per HPI.
GU: As per HPI.
Musculoskeletal: As per HPI. Also, denies loss of strength.
Neurological: as per HPI, also denies sudden unilateral weakness or loss of sensation, memory problems, or syncope.
Psychiatric: Denies symptoms of depression, and was negative on SIGECAPS questionnaire. Denies symptoms of mania (grandiosity, expansive mood, or irritability). He states that he does not feel anxious, or have symptoms of panic attacks (CP, palpitations, SOB, and nervousness). He states that he does not have any suicidal ideation.

PHYSICAL EXAMINATION:
VS: Upon presenting to the ER T=103.1 HR=98 RR=20 BP=139/88 (Right arm seated) oxygen saturation=99% on room air.
General: Patient is 59-year-old well-developed, slightly obese Caucasian male who appears his stated age. He is alert, oriented, and cooperative and in no acute distress.
Skin: Warm, dry with good turgor. Patient has mild pallor. No clubbing, cyanosis, or edema of extremities. No skin lesions, rashes, or petechiae. No nail bed changes.
HEENT: NC/AT. Sclera clear with no conjunctival injection. No hemorrhages, A-V nicking, papilledema, or exudates noted on fundoscopic exam. Oral mucosa moist, no sores or ulceration, teeth in good repair. Patient has mild pharyngeal erythema. Uvula and tongue midline.
Neck: Supple, trachea midline and freely movable. Thyroid not palpable.
Lymph nodes: No submental, submandibular, axillary, epitrochlear, cervical, supraclavicular or inguinofemoral adenopathy.
Lungs: CTAB, with good air entry. No wheezes, rales, or rhonchi. No accessory muscle use. No dullness or hyperresonance to percussion and no egophony.
CV: Regular S1, S2, no murmurs, gallops or rubs auscultated. PMI is at the left midclavicular line at the fifth-sixth rib. No JVD appreciated when patient is reclined at a 45 degree angle. No carotid bruits auscultated. +2 pedal, carotid, and radial pulses.
Abdomen: +BS in all four quadrants. Soft, NT/ND, with no HSM, masses or pulsations.
Renal: No CVA tenderness.
Rectal: No external lesions or hemorrhoids noted. Patient has good sphincter tone. No masses. Prostate smooth and uniformly enlarged. Guaiac not performed because of possible false positive results after rectal examination. No blood noted on glove after rectal exam.
Genitalia: No sores, rashes or ulcerations on penis or testicles, and no urethral discharge. Testicles are descended and do not appear to be atrophied. There are no masses or tenderness on palpation. No thickening or tenderness of epididymis.
Breast: Refused.
Neurological: EOMI intact with no nystagmus, PERRL, face symmetric, nasolabial folds appear equal bilaterally. Tongue and palate midline, normal tongue motion, no dysarthria. Muscle tone, strength 5/5, and bulk intact. No involuntary movements, spasticity, or fasiculations noted. Biceps, brachioradialis, triceps, patellar and Achilles tendon DTR +2. No pathological reflexes elicited. Sensory function, cerebellar function, and gait not tested.

EKG: 75 bpm, normal SR, PR 148 ms, QRS duration 100 ms, QT/QTc 372/404, L axis deviation, L anterior fascicular block, no ST segment changes or Q waves noted. There is no significant change from previous EKGs.

CHEST X-RAY:
No lung opacities, pleural disease, fractures, cardiomegaly, or hilar lymphadenopathy noted.

HELICAL CT OF THORAX, ABDOMEN, AND PELVIS:
Performed with oral and intravenous contrast. Medical student did not note masses, effusions, or fluid collection in pericardium or lung fields. No masses, fluid collections, or lymphadenopathy noted in abdomen or pelvis. Diverticulosis is noted, but inflammatory changes around bowel not observed. No inflammatory changes noted around gall bladder or pancreas.

CT results were reviewed with the radiologist and the report is included below for completeness.

Findings: Lungs are clear.  There is no pericardial or pleural disease. Heart size is within normal limits. There is no adenopathy.  The spleen is prominent in size. The visualized bowel loops are otherwise unremarkable.  The solid organs appear otherwise remarkable. There is no calcified gallstone or bile duct dilatation. The small right renal cyst is unchanged. The lung bases are clear. There is no pathologic lymphadenopathy in the retroperitoneum or mesentery. In the pelvis, there is no evidence of adenopathy or fluid collection. The prostate is not significantly enlarged. There is sigmoid diverticulosis with underdistention of the sigmoid colon. This makes it difficult to evaluate for subtle diverticulitis.  However, diverticulitis is not definitely seen. No evidence of acute pathology in the abdomen or pelvis. No significant change of abdomen and pelvis from a prior study performed on June 17, 2004.

TRANSTHORACIC ECHOCARDIOGRAM:
There is mild left atrial enlargement. The right atrium is also enlarged. Concentric left ventricular hypertrophy with normal wall motion and preserved systolic function. Ejection fraction is estimated to be 60%. Left ventricular chamber size is normal as well. There is mild right ventricular enlargement. There is slight thickening of the aortic valve cusps without obvious vegetation.  No significant aortic insufficiency is noted. There are myxomatous changes of the mitral valve without prolapse and only trace mitral regurgitation. The tricuspid valve appears to be normal in structure. There is mild to moderate tricuspid regurgitation. Pulmonary artery pressure is estimated to be 31 mmHg. No pericardial effusion is noted. No obvious evidence of valvular vegetation is seen.

LABS:
Performed by PCP two days ago:
Monospot negative, PSA screen 0.6, total cholesterol 136 mg/dL, triglycerides 253 mg/dL, HDL 18 mg/dL, LDL 67.4 mg/dL, WBC 6.2, HgB 13.3 g/dL, HCT 38.4%, MCV 85.3, RDW 14.7%, PLT 180 K/mm3, PMNs 56%, lymphocytes 28%, monocytes 16%, HgBA1c 5.2%, total protein 7 g/dL, albumin 3.9 g/dL, total bilirubin 1 mg/dL, direct bilirubin 0.2 mg/dL, alkaline phosphatase 125 units/L, SGOT 64 units/L, SGPT 96 units/L, TSH 1.49 mIU/mL, urine color yellow, clear, specific gravity 1.012, negative urine glucose, ketones, blood, bilirubin, nitrite, leukocytes, and protein. Urine pH 6.0.

Performed in the ED:
Na 132, K 4.3, Cl 95, CO2 26, BUN 26, Creatinine 1.3, glucose 92, Ca 8.8, Total protein 7.4, Albumin 3.8, Total bilirubin 1, Alk 127, SGOT 70 units/L, SGPT 108 units/L, RPR non-reactive, ANA negative, ESR 31 mm/hr , WBC 5.6, HgB 11.7, HCT 33.1%, MCV 84.9, RDW 15.2%, platelets 176. Fecal leukocytes negative. CRP 35.3 mg/L

SUMMARY STATEMENT:
59-year-old Caucasian male with a PMH of diverticulosis, presenting to the ER with an eleven day fever with no localizing symptoms, a one month history of muscle aches and general malaise, and a one year history of diarrhea alternating with constipation. Patient also recently had unprotected sexual intercourse with an exotic dancer. Imaging studies do not suggest an obvious source of the fever. Patient has mildly elevated liver transaminases, elevated ESR and CRP, and a borderline microcytic anemia.

PROBLEM LIST:

1. Fever without localizing signs, elevated serum transaminases, ESR, and CRP.
2. Chronic GI complaints: diarrhea interspersed with constipation and early satiety.
3. Borderline hypertension.
4. Erectile dysfunction.
5. High-risk sexual behavior.
6. Previous history of alcoholism.
7. Borderline microcytic/normocytic anemia.
8. Diverticulosis with guaiac positive stools two days ago.
9. Dyslipidemia.
10. Basal cell carcinoma of left lower eyelid excised in 1994.
11. Hesitancy/nocturia/difficulty starting and stopping stream of urine.
12. History of SVT.

DISCUSSION AND PLAN:
Fever without localizing signs, elevated serum transaminases, ESR, and CRP.

A discussion of the workup of fever of unknown origin is quite broad and will be deferred in favor of a more focused approach tailored to this patient. Fever of unknown origin is classically defined as a temperature greater than 38.3 degrees C (100.9 degrees F) for more than three weeks with no obvious source of infection despite thorough clinical workup (Roth and Basello 2003). This patient does not strictly meet these criteria because his fever has lasted less than two weeks and his workup has just been initiated.

A meta-analysis of etiologies of FUO suggests that infections are the cause of fever 28% of the time, followed by inflammatory diseases (21%), malignancies (17%), temporal arteritis (16%) and deep vein thrombosis (3%) (Shaughnessy 2003). 19% of patients with FUO never have a diagnosis, but half of this population recovers spontaneously without treatment.

The patient should be pan-cultured in order to localize a possible site of infection. The patient may be predisposed to urinary tract infections because of benign prostatic hypertrophy (discussed later) and therefore urinary cultures should be sent despite the negative urinalysis. Furthermore, acute bacterial prostatitis may also present with positive urine cultures (discussed below). The patient does not have any cough or sputum production and therefore, sputum culture is not likely to be helpful. Nevertheless, tuberculosis is an often-overlooked potential cause of FUO. The patient does not have any positive findings on chest x-ray and thoracic CT scan. Unfortunately, conventional chest x-rays have a very low sensitivity and specificity of pulmonary tuberculosis (Al Zahrani et al., 2000). Thoracic CT scans are more sensitive, but can still miss ~25% of pulmonary tuberculosis infections (Tateishi et al., 2002). Sputum culture should be attempted in this patient and stained for AFB regardless of the chest imaging results. Skin testing for TB using PPD is inexpensive, but is not a sensitive or specific tool for diagnosing this disease. Furthermore, TB can manifest itself in almost any extrapulmonary site, but once again, tissue must be obtained from the site of tuberculosis infection and tested by growing in culture or by polymerase chain reaction. At this time, there is no obvious source of pulmonary or extrapulmonary infection, but I would still recommend a PPD skin test despite its lack of sensitivity or specificity.

This patient requires blood cultures to detect bacteremia and possible infective endocarditis. Blood cultures should be obtained during a febrile episode. Three to four blood cultures at different sites, separated by one hour or more are recommended. The site of venipuncture should be prepared by alcohol and iodine in order to prevent false positive cultures from skin flora. The most likely causes of infective endocarditis are staphylococcus aureus, viridans streptococci, and enterococci. It is also possible to have culture negative endocarditis due to Coxiella burnetti, Tropheryma whipplei, Brucella, Mycoplasma, Chlamydia, Histoplasma, Legionella, Bartonella, as well as the HACEK organisms (Haemophilus aphrophilus, actinobacillus actinomycetemcomitans, cardiobacterium hominis, Eikenella corrodens, and Kingella kingae; which do not grow unless blood cultures are kept for 7-21 days). A further workup of these less common causes of infective carditis should be delayed until there is more clear evidence of infective endocarditis by echocardiogram. A transthoracic echocardiogram did not show vegetations and only “myxomatous changes” were noted on the mitral valve. Transesophageal echocardiogram has a higher sensitivity and specificity for detection of endocarditis than transthoracic echocardiogram and should be considered for this patient. Throat culture and ASO titers should be obtained in order to rule out rheumatic fever, which is unlikely with this patient because of the lack of carditis, polyarthritis, chorea, and characteristic skin changes.

The patient has elevated liver transaminases and should be tested for common causes of hepatitis, including Hepatitis A-E, EBV, and CMV. Acute viral hepatitis can be diagnosed by IgM anti-hepatitis A virus, IgM anti-hepatitis B core antigen, Hepatitis B surface antigen, and anti-HCV. Chronic viral hepatitis is diagnosed by the presence of Hepatitis B surface antigen and anti-HCV. The monospot test was negative, but IgM levels for EBV and CMV should also be considered. Autoimmune chronic hepatitis is considered if there are persistently elevated liver transaminases and the patient is seronegative for the Hepatitis viruses. Several tests, including antinuclear antibody, anti-smooth muscle antibody, anti-liver-kidney microsomal antibodies, and anti-cytokeratin antibodies may be positive with autoimmune hepatitis. A more detailed history of Tylenol use should be elicited in order to rule out drug-induced hepatitis. Although unlikely, the patient should also be questioned further about his alcohol consumption to rule out alcoholic hepatitis. SGOT and SGPT levels should be monitored over time and liver biopsy should be considered if these values worsen without any apparent etiology, which would help diagnose the most common cause of chronic hepatitis, nonalcoholic steatohepatitis.

Because of this patient’s sexual history, he is at risk for HIV infection. He has never been tested for HIV in the past, but has purportedly not been sexually active in the last twenty years. His only sexual encounter was unprotected intercourse and oral sex with an exotic dancer two weeks ago. This patient may be suffering from an acute HIV infection. Although physical manifestations of acute HIV infection were not noticed on physical exam, such as rash, mucocutaneous ulcers, and lymphadenopathy, this patient should be re-evaluated frequently for these symptoms. This patient should have a traditional HIV antibody test, which would not detect an acute infection from two weeks ago, but would help determine if he has been chronically infected with HIV. In order to diagnose an acute HIV infection, a viral load test and a p24 antigen test should be performed. If the HIV antibody test is negative and the HIV viral load test and p24 antigen test is positive, this is suggestive of an acute HIV infection.

Nuclear medicine scanning, including using radiolabeled leukocytes has been helpful in estabilishing the diagnosis in 30% of cases of FUO, which is substantially greater than ultrasound and CT because the whole body is examined (Knockaert et al., 1994). Nevertheless, the role of nuclear medicine scanning for diagnosis of FUO is controversial and should be considered when the initial battery of laboratory results and imaging is negative.

Other infectious causes of FUO, including Lyme disease, sinusitis, osteomyelitis, or dental, abdominal or pelvic abscesses are not consistent with the physical exam or CT. Furthermore, lumbar puncture is not indicated because of the lack of neurological symptoms.

The patient does not have any symptoms of malignancies such as leukemias, lymphomas, renal cell carcinomas, or metastatic cancers besides his fever. There is no physical exam or radiological evidence of any tumors. A lymph node biopsy would be warranted if there was lymphadenopathy found. It is possible that the patient has a gastrointestinal lymphoma that may be causing his GI symptoms as well as his fevers. An EGD and colonoscopy should be helpful in the diagnosis of a GI lymphoma and a SPEP and UPEP can be performed to rule out lymphoproliferative disease. There is no evidence for any other type of malignancy. A bone marrow biopsy can be performed to rule out miliary tuberculosis or leukemia but should not be performed early in the patient’s workup because of the invasiveness of the procedure and the low clinical suspicion for these disorders.

Inflammatory diseases such as temporal arteritis and other vasculitides, inflammatory bowel disease, SLE, rheumatoid arthritis, and polymyalgia rheumatica are other causes of FUO. The patient has a negative ANA, but an elevated ESR and CRP, suggesting an underlying inflammatory process. The patient does not complain of any symptoms that are particular to the above diseases. He does not complain of any jaw claudication, vision changes, or headaches that are commonly associated with temporal arteritis. It is unlikely that he has rheumatoid arthritis and polymyalgia rheumatica because of the lack of joint symptoms. Furthermore, IBD is unlikely because of the unremarkable sigmoidoscopy four years ago and the mild GI symptoms. The presence of vasculitides can be tested by measuring C3 and C4 levels.

The diagnosis of FUO is challenging. The history needs to be revisited with the patient a number of times and a full physical exam should be repeated often in order to focus the diagnosis in this patient. Furthermore, invasive tests without specific localizing symptoms, such as liver and bone marrow biopsies should be reserved as a “last resort” in order to prevent unnecessary complications. In this patient, liver enzymes, ESR, and H & H should be followed over time. An infectious disease consult should also be considered.

Chronic GI complaints: diarrhea interspersed with constipation and early satiety.
The causes of diarrhea and constipation are vast. Instead of providing a broad overview of diarrhea and constipation diagnosis and management, the following will focus on the patient’s specific symptoms. In particular the patient has had abdominal distension and discomfort, which is relieved by defecation. The patient complains of chronic episodes of diarrhea interspersed with days of constipation. Patient does not complain of nocturnal diarrhea, bloody or black tarry stools, weight loss, or malodorous, or greasy stools. Fecal leukocytes are negative which suggests that inflammation and infection are unlikely. The patient’s TSH is within normal limits, suggesting that hyperthyroidism is unlikely. The constellation of GI symptoms which have persisted for more than a year are highly suggestive of irritable bowel syndrome. Nevertheless, because of the positive occult blood and the fever without localizing signs, further investigation for an alternative cause of diarrhea/constipation is warranted. As discussed above, EGD and colonoscopy may be helpful in elucidating an organic cause for the patient’s symptoms such as GI malignancy, inflammatory bowel disease, or malabsorptive syndromes. Before these invasive tests, stool cultures, stool for ova and parasites, C. dificile toxin, 24-hour stool collection, Sudan stain, and tissue transglutaminase levels should be considered. C. dificile infection is unlikely because the patient’s diarrhea has persisted for more than one year and there is no history of recent hospitalization or antibiotic use. 24-hour stool collection may be helpful to quantify the amount of stool. The patient complains of “diarrhea”, which may not be a large volume of stool, but multiple small bowel movements. Parasites, such as giardia often cause chronic diarrhea and must be ruled out in this patient. The patient may have an atypical presentation of celiac sprue, and therefore tissue transglutaminase levels are measured. A sudan stain is used to determine the presence of steatorrhea.

If the above-mentioned tests do not reveal an organic cause of diarrhea, the diagnosis is highly suggestive of irritable bowel syndrome. First, the patient should be encouraged to keep a food log and write down food associated GI symptoms. Certain foods may cause gas, diarrhea, or abdominal pain, and should be avoided. Similarly, patients should consider a trial of a lactose free diet in order to rule out lactose intolerance, which has a similar presentation to IBS. Several serotonin receptor antagonists, such as alosetron and tegaserod have been shown to be effective for women with IBS, but have not been effective for men. Generally, patients with mild symptoms are reassured and educated about their condition. Dietary changes are suggested as above, and fiber supplementation is often recommended. For more severe symptoms, psychotherapy and antidepressants can be considered.

Borderline hypertension.
Patient’s blood pressure was in the pre-hypertension range today as per JNC 7 guidelines. Patient also states that his blood pressure has been in this range for about ten years and he has never taken any medications for it. This patient is obese and could benefit from lifestyle modification including regular aerobic exercise and weight reduction that may also improve his dyslipidemia. This patient does not have any evidence of end-organ damage from hypertension, including retinal changes, heart disease, or stroke. Furthermore, at first glance there is no evidence of renal disease because his serum creatinine is 1.3, which is within normal limits. Nevertheless, according to the MDRD GFR calculator, http://www.nephron.com/mdrd/default.html, this patient’s creatinine clearance is 60 ml/min/1.73 m which is classified as chronic kidney disease of stage 2-3 (as defined by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative at http://www.kidney.org/professionals/doqi/kdoqi/p4_class_g1.htm). This patient’s renal disease may be due to hypertensive nephrosclerosis, which warrants more vigilant blood pressure control. Diuretic therapy, such as hydrochlorothiazide 12.5 mg qday may be considered first line therapy for hypertension, but may exacerbate this patient’s nocturia. As discussed in a following section, because this patient is averse to medications, perhaps he should be treated with an alpha-blocker, such as terazosin 1 mg qHS which will lower his blood pressure as well as relieve his urinary tract symptoms. Alternatively, an ACE inhibitor, such as lisinopril 10 mg qday should be considered.

Erectile dysfunction.
The etiology of this patient’s erectile dysfunction (ED) is unknown and may include endocrine disorders, vascular disease, neurogenic ED, psychogenic ED, or neuromuscular junction disorders. The patient was not interested in exploring the etiology of his ED at this time. Regardless, the patient feels that his symptoms are well controlled with sildenafil, which was originally started in April 2004. The patient has several risk factors for vascular disease, including hypertension and dyslipidemia. Treatment of these disorders may preserve vascular function if this is the etiology of his ED. Nevertheless, treatment of hypertension with a beta-blocker may contribute further to his erectile dysfunction because this is a common side effect of this class of medication. Other antihypertensives, such as diuretics and ACE inhibitors rarely cause erectile dysfunction and therefore should be considered first.

High risk sexual behavior.
Patient states that he had unprotected intercourse with a female exotic dancer two weeks ago. He states that he has never had sex with men and that he has not been sexually active in the last twenty years before two weeks ago. A workup for common sexually transmitted diseases is warranted for this patient because of his fever of unknown origin. HIV and hepatitis infections are discussed in the above section. The patient does not complain of pain or burning with urination, urethral discharge, testicular pain, sores, rashes, or joint pains. On physical exam, no chancres, discharge, ulcers, or adenopathy were noted. It is therefore unlikely that the patient has gonorrhea, chlamydia, HSV, or syphilis. Nevertheless, a swab should be inserted into the urethra about 2-3 cm and the sample should be gram-stained in order to check for the presence of organisms or neutrophils. With Neiserria gonorrhoeae, gram negative diplococci are found inside neutrophils. Gonorrhea should be treated with one dose of ceftriaxone 125 mg IM followed by one dose of azithromycin 1 g PO (for possible concurrent chlamydia infection). Non-culture methods are available for T. pallidum, HSV, HPV, and Chlamydia infections and are more rapid than culture methods. Patient was counseled on the importance of consistent use of condoms to prevent STDs.

Previous history of alcoholism.
Patient has been “dry” for 24 years and does not have a desire to start drinking again.

Borderline microcytic/normocytic anemia.
Patient has borderline normocytic/microcytic anemia of unknown etiology. First a reticulocyte count should be measured which is often elevated during a hemolytic process or during acute blood loss. A high reticulocyte count would warrant further workup of potential sites of blood loss, especially the GI tract in this patient. A hemolytic process is unlikely in this patient because the total, direct, and indirect bilirubin are within normal limits. Nevertheless, a peripheral blood smear would suggest evidence of a hemolytic process with the presence of schistocytes, target cells, or sickle cells. The patient requires iron levels, total iron binding capacity, and ferritin levels and his peripheral blood smear should be examined. Iron deficiency anemia would be suggested by low iron and ferritin levels and high total iron binding capacity. Thalassemia would manifest with relatively normal iron profiles. It is possible that this patient is suffering from anemia of chronic disease (ACD) because of elevated acute phase reactants, ESR and CRP. ACD is diagnosed by low iron and TIBC and high ferritin levels and is treated by correcting the underlying chronic disease. A further discussion of potential chronic diseases in this patient is described in the previous section.

Sigmoid diverticulosis. Patient was diagnosed with diverticulosis after a routine flexible sigmoidoscopy in 2000, which was otherwise unremarkable. The patient has not complained of bleeding per rectum or black tarry stools, but the PCP noted guaiac positive stools from a rectal exam two days ago. This may be a false positive test because of trauma during the rectal exam. Alternatively, the guaiac positive stools could be attributed to internal hemorrhoids. Nevertheless, this should be investigated further because of the patient’s anemia, and the apparent fall in his hematocrit from 38% to 33% in two days. The patient’s H & H should be monitored while the patient is in the hospital to determine if this was in fact a spurious laboratory result. Furthermore, localization of the site of bleeding to the upper GI tract or the lower GI tract should be attempted. Because of the occult bleeding, and the lack of upper GI symptoms, passing a nasogastric tube and examining the aspirate for blood may not be helpful. An EGD and colonoscopy may be required to identify the source of bleeding. It is important to confirm that the patient has not been taking NSAIDs or aspirin as antipyretics, which may cause gastritis and occult bleeding. A proton pump inhibitor such as omeprazole 40 mg qday may be considered if gastric inflammation or upper GI ulcers are the cause of the patient’s bleeding. At this time the patient is hemodynamically stable and does not require rbc transfusion.

Dyslipidemia.
Patient was diagnosed with dyslipidemia by his PCP, but the patient has not taken medications in the past. His last lipid panel showed a total cholesterol of 136, triglycerides of 253, HDL of 18, and LDL 67.4. According to ATP III guidelines, this patient’s LDL levels are optimal regardless of his cardiac risk factors. Nevertheless, this patient has very low HDL levels as well as hypertriglyceridemia. Because this patient has met his LDL goals, and is averse to drug therapy, the importance of lifestyle modifications, including weight management, physical exercise, and a low saturated fat, low cholesterol, high fiber diet should be emphasized. Niacin 50 mg PO BID (with gradually increasing doses) may improve the patient’s lipid profile, but may be difficult to tolerate because it may worsen his diarrhea as well as cause cutaneous flushing. A fibric acid derivative, such as gemfibrozil 600 mg PO BID, may also be considered to reduce his hypertriglyceridemia, but the primary treatment modality should be lifestyle modification.

Basal cell carcinoma.
Patient has not had a recurrence of this skin cancer of the left lower eyelid that was completely excised in 1994. No suspicious skin lesions were noted on exam at this time and patient has been vigilant for new skin lesions.

Hesitancy/nocturia/difficulty starting and stopping stream of urine.
Because of the patient’s age, the lower urinary tract symptoms of the patient are highly suggestive of benign prostatic hypertrophy (BPH). Accordingly, the digital rectal exam revealed a diffusely enlarged non-tender prostate gland. Nevertheless, his urinary symptoms may also be due to other more unlikely causes such as diabetes mellitus, neurological diseases, or structural problems with the lower urinary tract. This is unlikely because of a normal HgBA1c and fasting glucose. Also, the patient does not have any focal neurological symptoms. In this patient, prostatitis due to an infectious or inflammatory etiology may cause lower urinary tract symptoms and manifest as fever of unknown origin. This is unlikely because his urinary tract symptoms have gradually worsened over the last several years and does not correlate with the more recent onset of fever. Nonetheless, chronic bacterial prostatitis commonly presents with voiding difficulties as well as sexual dysfunction, such as in this patient. Chronic bacterial prostatitis can be diagnosed by urinalysis and culture of first voided urine, midstream urine, and post-prostate massage urine. In chronic bacterial prostatitis, post-massage urine often shows markedly elevated numbers of wbcs on urinalysis and greater numbers of organisms on urine culture. Chronic bacterial prostatitis is often treated with trimethoprim-sulfamethoxazole 80 mg/400 mg PO BID or a fluoroquinolone, such as gatifloxacin 200 mg PO qday for 6-12 weeks. Of course, the choice of antibiotic should be guided by culture results. Alternatively, the patient may suffer from chronic nonbacterial prostatitis, which is in fact more common than BPH. In this disorder, urinalysis is generally within normal limits and supportive treatment is recommended, including NSAIDs and warm baths. Oftentimes two-week courses of antibiotics are attempted with these patients and are continued if patients respond.

For this patient, routine urinalysis is within normal limits. A urine culture is warranted. If there are no localizing signs later in treatment, pre- and post-prostate massage urinalysis and urine culture should be considered. Nevertheless, it is likely that the patient suffers from BPH. Because of the subjectivity of lower urinary tract symptoms, treatment should be guided by the patient’s comfort and the perceived disruption of his life by his symptoms. If the patient would be amenable to treatment, I would recommend an alpha-blocker such as tamsulosin 0.4 mg PO qday because of its minimal side-effect (orthostatic hypotension and dizziness) profile. Alternatively, it may be beneficial to try terazosin 1 mg PO qHS because it may also improve this patient’s hypertension.

(For the previous section, the following reference was consulted: Chapter 71: Men’s Health Topics, in Andreoli TE: Cecil essentials of medicine, 6th edition. Philadelphia, WB Saunders, 2004.)

History of SVT.
Patient only had one episode of SVT and spontaneously reverted back to SR at that time. He is not on medication for heart rhythm disturbances at this time.

Health maintenance issues, including immunizations were not reviewed with the patient at this time.

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