Mrs. C is a 69-year-old white woman who has enjoyed good health over the years. Other than a diagnosis of osteoporosis, she has no medical history. She came to our clinic with vague complaints of approximately a week’s duration. Predominantly, she noted presyncope and lightheadedness, fatigue and mild upper abdominal pain.
Two nights prior to presentation, Mrs. C arose from sleep to urinate when, just before micturition, she felt dizzy and subsequently had to sit down on the bathroom floor. She was shaky and sweaty, but after a few moments the symptoms passed and she went back to bed. When she was seen in the office she still noted lightheadedness upon standing and a generalized sense of malaise.
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1. History
The patient had not noted any unintentional weight changes, fevers, chills or sweats. There was no cough or shortness of breath, nor were there any respiratory symptoms. Moreover, she denied chest pain and exertional dyspnea.
Mrs. C admitted to occasional palpitations, but they were fleeting, unassociated with any other symptoms and unchanged over the years. She reported mild nausea, but no vomiting. She stated she had mild, intermittent, sharp pains in her upper abdomen that were not associated with food, and no significant belching or indigestion. She said she had loose bowels since the onset of symptoms, but no frank diarrhea and, importantly, no bloody or dark stools. There were no urinary changes. Further probing indicated that the patient bruises easily, but she stated that this is not a new finding for her, and she attributed it to taking a daily aspirin.
In addition to taking 81 mg of aspirin per day, Mrs. C was on weekly alendronate (Fosamax), fish oil, a calcium supplement and a multivitamin.
2. Examination
Physical examination showed an afebrile woman appearing younger than her stated age. Her vital signs were: temperature 98.0°F orally, BP 92/52 mm Hg sitting and 82/50 mm Hg standing, pulse 84 beats per minute and regular, respiratory rate 16 breaths per minute, weight 141 lb. (down 8 lb. from one year prior) and height 64.5 in. Her head and neck exam were unremarkable, as were her ears, nose and throat. Notably, her mucous membranes were moist. There was symmetric expansion of the chest, and lungs were clear to auscultation and percussion bilaterally. On cardiovascular exam the patient was found in a regular rhythm, with S1 and S2 intact and no audible clicks, murmurs or rubs.
Mrs. C’s abdomen was normoactive with bowel sounds, tympanic, soft and mildly tender to deep palpation of the left upper quadrant. On examination, her spleen felt enlarged. However, there were no other masses or organomegaly noted. Mrs. C’s skin was nondiaphoretic and nonicteric, but presented with a few small ecchymoses about the legs, which were nontender. Notably, her conjunctivae were pale, and she had a right medial subconjunctival hemorrhage, which was already in the healing stage. No edema was present.
At this juncture the differential diagnosis for Mrs. C included but was not limited to: anemia, unspecified thrombocytopenia, dehydration, adrenal insufficiency, malignancy and infectious process.
3. Laboratory Data
The patient was sent for a complete blood count and comprehensive metabolic profile. The results showed: nonfasting glucose 124 mg/dL; blood urea nitrogen 11.5 mg/dL; creatinine 0.8 mg/dL; sodium 139 mEq/L; potassium 4.6 mEq/L; calcium 8.3 mEq/L (ref range 8.6-10.2); total bilirubin 0.7 mg/dL; alkaline phosphatase 124 units/L (ref range 35-104); alanine aminotranferease 307 units/L (ref range 0-31); aspartate aminotransferase 374 units/L (ref range 0-31); total protein 5.8 g/dL (ref range 6.4-8.3); albumin 4.3 g/dL (ref range 3.4-4.8).
Mrs. C’s blood count was remarkable in that WBC was 18,000/ml. The differential was set up manually and further revealed neutrophils at 23 (ref range 39.3-73.7%), and lymphocytes 68 (ref range 18.0-48.3%). Hemoglobin and hematocrit were 12.2% and 36.9%, respectively. There was modest thrombocytopenia. Confusing the issue, the laboratory technicians suspected blastocytes on microscopic evaluation and requested a pathology review. However, the official report from pathology was negative for blastocytes.
Lactate dehydrogenase was later found to be high, at 342 units/L, and a hepatitis panel was negative.
