March ’12

Medical Student Elective

Case of the Month
Submitted by: Peggy Tseng, MS4 Columbia P&S

A 25 year old man with insulin dependent diabetes presents with chief complaint of fatigue, headache, and shortness of breath for 1 day. The patient noticed a gradual onset of a headache, dyspnea on exertion, shortness of breath, and generalized weakness for 1 day prior before presentation. He denies any cough, fever, or recent illness. The patient has been taking his insulin as prescribed, and he denies any alcohol, illicit drug use, or other recent prescription drug use. No associated symptoms of chest pain, nausea, vomiting, abdominal pain, or blood in his urine or stool.

IDDM, no prior surgeries.
Social history: Smokes 4-6 cigarettes a day for 6 years, emigrated from Yemen 16 years ago, no recent foreign travel, works in a deli shop.

PE (pertinent)
Vitals: Temp 99.5F oral, BP 116/71, RR 108, RR 18, O2 Sat 77% on room air
Constitutional: tired appearing, pale complexion, no acute distress.
Eyes: sclera non-icteric.
Cardiovascular: regular rate and rhythm, normal S1 and S2, no murmurs.
Respiratory: clear to auscultation bilaterally, no rales, rhonchi, or wheezes, breath sounds equal bilaterally.
GI: soft, non-distended, non-tender to palpation.
Rectal: guaiac positive, normal color stool.
Muscleskeletal: no cyanosis, no calf tenderness, normal appearance.
Dermatological: pale skin, no rashes or petechiae.

Normal sinus rhythm, 95 beats per minute, no ST T wave changes.

Chest — normal, no evidence of effusion or pneumothorax.

CBC: Hemoglobin 9.4, WBC and Platelets normal
Reticulocyte count: 0.82%
Metabolic: Glucose: 302 mg/dL, BUN and Creatinine normal, Calcium 7.9 mg/dL, Potassium and CO2 normal
LFT: Total protein 6.0 g/dL, Albumin 3.3 g/dL, Alkaline Phosphatase and ALT normal, AST 90 U/L, Total bilirubin 7.3 mg/dL, Direct bilirubin 0.0 mg/dL
Arterial Blood Gas on Room Air: pH 7.50, pCO2 40.0 mmHg, pO2 95.3mmHg, O2 saturation 97.5%

The patient was placed on 100% non-rebreather, and O2 Sat increased to 85%. Patient was then placed on Bipap, and felt more comfortable and less weak. However, O2 remained 85% while patient was in the ED.

What further tests would you order on this patient?

What further tests would you order on this patient?

Carboxyhemoglobin level: 2.9% (high for non-smokers, but normal for a smoker)
Methemoglobin level: 7.8% (normal 0.2-0.6)
LDH: 3733 U/L (normal 313-618)
CT Angiogram: normal, negative for pulmonary embolism.

Why would this patient have methemoglobinemia?
Why is he so short of breath and anemic?

Patient was transferred to ICU for continued care and monitoring. Over the next 2 days, the patient displayed evidence of hemolysis with hemoglobin drop to 6.2 g/dL, persistent bilirubinemia with jaundice, and LDH rise to 9617 U/L. Blood smear was analyzed and showed bite cells, implying the diagnosis of G6PD deficiency! The patient was transfused and supported, and he began to do better and was transferred to the regular medical floor after 2 more days. The diagnosis cannot be confirmed while the patient was still recovering from this hemolytic episode, but in a few months he will have his G6PD deficiency levels measured as an outpatient.

Every month during director’s rounds, our students present interesting and educational cases. This is a synopsis of the case voted to be the best by the students and directors at the end of director’s rounds along with an interesting image.


Medical Student Program Directors

Jamie Edelstein, MD and Chen He, MD


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