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Case Number : 3 Chief Complaint : 54 y/o male with vomiting/mild abdominal pain times 10 days Presented by : Phil Seidenberg
History of Present Illness The patient is a 54 y/o male with PMH significant for hypertension, CVA in 2000 with residual left arm weakness, left 7th nerve palsy.  Pt has had mild abdominal cramping with intermittent nausea/vomiting times 10 days, no reported fevers, no chills.  Pt states he has been vomiting 4-5 times per day, non-bilious, non-bloody.  He describes the pain as diffuse cramping, denies diarrhea, no relation to eating, intermittent in nature.  Last BM approx 5 days ago.  Pt also describes decreased PO intake, decreased urine output for the last 4-5 days. Pt also reports difficulty with emotions over the past 10 days, increased life stressors including mom’s death and sister’s stroke.  He states that he doesn’t ‘feel right,’ slightly histrionic with multiple episodes of uncontrollable crying which he says is not normal for him.  He denies HA/dysarthria/ vision changes/neurologic abnormalties. Pt has no history of previous abdominal surgeries, states he has a 10 pound weightloss over the last 2 weeks. ROS- no dysuria/hematuria, no CP, no SOB, slight lower back pain, no rashes, no recent travel/illnesses, pt admits to chronic smoker’s cough, occasional nightsweats PMH- HTN, CVA in ’00 with residual left 7th nerve palsy, left arm weakness Meds- HCTZ, ASA Social- long history of smoking, occasional ETOH, no drugs, no hx IVDA
Physical Exam Vitals T 37.8 BP 146/87 HR 105 RR 16 O2Sat 93% GEN A/Ox3, Crying intermittently during interview HEENT NC/AT Eyes- 2.5mm Bilaterally, Reactive, no nystagmus, EOMI Oral- mucosa dry, no lesions Neck- supple, no JVD, no LAN Lungs- slightly diminished diffusely, no rhonchi, no wheezes CV- RR, tachy, NlS1S2, no appreciable murmurs Abd- Soft, non-distended, mild mid-epigastric tenderness, no rebound , no guarding, no hepatomegaly Rectal- enlarged, firm prostate, guaiac neg Skin- warm/dry, no lesions Back- mild lower L-spine tenderness to palp, no bony abnormalities Neuro- 7th nerve palsy to left, hyperreflexive DTRs, no clonus, slight weakness in left UE, nl cerebellar function
Differential Diagnosis 1.        Gastritis 2.        Depression with abdominal symptoms 3.        Pancreatitis 4.        Electrolyte abnormality (particularly hypercalcemia) 5.        Hyperthyroidism 6.        Hepatitis 7.        GERD/PUD 8.        Renal insufficiency/failure 9.        Dehydration 10.     Colon/Gastric CA 11.     Frontal Lobe CVA
Laboratory Values WBC- 11,000 with nl differential Hgb/Hct- 16/48 Plts- 200,000 Na- 138 K 4.7 Cl 110 Bicarb 27 BUN 22 Cr 2.4 Mg 1.7 Ca 15.7 LFTs- TBili 1.0 Albumin 4.0, AlkPhos 117 ALT/AST- nl U/A- 1.105, 1+ proteinuria, no casts, no WBC/RBC CK- 170 Lipase- nl Head CT Scan- normal
Clinical Course Given the hypercalcemia in the setting of oliguric renal failure, the pt has hydrated with 2L NS and medicine was called for an admission.  An ECG as well as CXR was done( not pictured), PSA, PTH sent. The chest x-ray  showed multiple diffuse, peripheral lung densities suspicious for cancer.   Pamidronate was not given in the ER, nor was Lasix, although floor orders for lasix with significant fluid hydration were written. Hypercalcemia causes a variety of symptoms, the most common ones being altered or changed mental status and GI effects.  The CNS effects range from lethargy, confusion, personality changes, depression, to frank coma.  The most common GI effects are nausea, vomiting and anorexia with mild abdominal pain.  The most common causes of hypercalcemia are parathyroid abnormalities followed by tumors (typically multiple myeloma, metastatic cancers, leukemias and lymphomas, and lung cancer.  Granulomatous diseases (sarcoidosis), drug-related (in particular lithium, thiazide), hyperthyroidism, Vitamin D intoxication and Paget’s Disease are other less likely causes.  Hypercalcemia can cause ECG changes (shortened QTc interval) as well as renal failure.
Final Diagnosis 1.       Hypercalcemia 2.        Acute Renal Failure 3.        Metastatic Lung Cancer
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