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Case of the Week March 31th, 2010 HPI: 51 yo M presents for evaluation of numbness, tingling and weakness in his lower extremities. Started several weeks ago in his feet and has progressively worsened. At first was just a tingling sensation in his feet, then it progressed to a sensation of numbness with accompanying weakness that spread up to his thighs. He has no hx of diabetes or sciatica. No incontinence. He also mentions that he thinks he a lost some weight recently (~20 lbs in the last 2-3 months) and seems to be fatigued. He complains of mild shortness of breath without cough or chest pain. No night sweats, fevers or chills. His appetite has been reduced, but no n/v/d/c. No hematuria or dysuria, nor change in urinary volume/frequency. Allergies: NKDA Medications: HCTZ 25 mg daily, ASA 325 mg daily, albuterol MDI prn PMHx: HTN, mild exercise induced asthma Social Hx: Divorced, no children. Works as an electrician. Quit smoking 10 years ago, previously smoked 1 ppd x 15 yrs. Occ EtOH use. No hx illicit drug use. Family Hx: Adopted. Exam: Afebrile, BP 145/95, HR 89, RR 16, Sat 99% RA Gen: adult male in no distress, but appears exhausted Head/Neck: EOMI, no thyromegally CVS: RRR, S1 & S2 nl without murmurs Lungs: diminished breath sounds R base with few crackles, no wheezing Abd: +BS, soft, NT/ND, mild hepatomegally with liver span estim 15 cm GU: bilat small testicles, normal rectal tone Ext: No evidence of muscle wasting. No gross joint deformities. 1+ LE edema. Skin: patchy coarse black hair noted on extremities with apparent hyperpigmentation Neuro: CN intact. Strength 2/5 in bilat LE. Touch and vibratory sensations are diminished in all areas of bilat LE. Labs/Studies: · WBC 12,000; Hb 13; Plts 461,000 · BMP wnl · Total Protein 8.3 g/dl, Albumin 3.1 g/dl · LFTs wnl · Fasting serum glucose 96, A1C 5.5% · B12 & folate levels wnl · TSH, FT4 wnl · Low testosterone level · Elevated VGEF level · CXR: moderate sized R pleural effusion, a mixed lytic & sclerotic lesion involving R 2nd rib · Echo: normal systolic and diastolic function, no significant valvular abnormalities · EMG: findings consistent with a demyelinating polyneuropathy · SPEP:

What's the diagnosis? Send your answers to [email protected] by Tuesday, April 13th by 3 pm. Next Grand Rounds Wednesday, April 14th (No Grand Rounds April 7th).


Microsoft Word - COW 03-31-10.doc

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