Internal Medicine Case Challenge: A Highly Active 80-Year-Old Woman With Sudden Illness

Zafar Jamkhana, MD, MPH; Nirav Patel, MD


April 03, 2023

Physical Examination and Workup

On physical examination, the patient is an elderly woman who is slightly confused and short of breath. Her blood pressure is 80/50 mm Hg, respiratory rate is 32 breaths/min, heart rate is 120 beats/min, and temperature is 100.6°F (38.1°C). She is oriented to self and spontaneously moves all extremities. She has slightly icteric conjunctiva. She has a patent airway with bilateral rales and diminished air entry in both the lung bases. She has normal S1 and S2 heart sounds. Her abdomen is mildly distended, without tenderness, and bowel sounds are present. No rash is noted on skin examination.

Laboratory results revealed the following:

  • White blood cell count: 2500 cells/µL (reference range, 3500-10,500 cells/µL), with 65% neutrophils (reference range, 30%-60% neutrophils) and 18% bands

  • Serum hemoglobin level: 5.8 g/dL (reference range, 12-15.5 g/dL)

  • Platelet count: 88,000 cells/µL (reference range, 150,000-400,000 cells µL)

  • Serum creatinine level: 2.9 mg/dL (reference range, 0.6-1.2 mg/dL)

  • Serum urea level: 54 mg/dL (reference range, 7-26 mg/dL)

  • Serum alanine aminotransferase level: 124 U/L (reference range, 0-55 U/L)

  • Serum aspartate aminotransferase level: 673 U/L (reference range, 5-34 U/L)

  • Serum bilirubin level: 2.8 mg/dL (reference range, 0.2-1.2 mg/dL)

  • Serum lipase level: 167 U/L (reference range, 8-178 U/L)

  • Serum lactate level: 4.6 mmol/L (reference range, 0.5-2.2 mmol/L)

  • Serum ferritin level: >21,000 ng/mL (reference range, 13-24 ng/mL)

  • Serum triglycerides: 385 mg/dL (reference range, <150 mg/dL)

Her peripheral smear does not show schistocytes. Her chest x-ray reveals diffuse bilateral interstitial and patchy air space opacities, along with moderate bilateral pleural effusions. An example of a similar x-ray is shown in the figure below.




Computed tomography scanning of the abdomen is nonrevealing but confirms the bilateral pleural effusions and demonstrated ground glass opacities on the available lung sections.


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