A Woman With AF After Husband’s Death, Grandkids’ Drug Abuse

Asim Kichloo, MD; Nadir Siddiqui, MD; Nazir Lone, MD, MPH; Mohamed A. Mohamed, MD


November 16, 2022

Physical Examination and Workup

The patient is thin and appears frail. She is receiving 2 L/min of oxygen through a nasal cannula. Her body mass index (BMI) is 18 kg/m2, and her neck circumference is 14 inches. Her blood pressure is 167/90 mm Hg, and her pulse is regular at 77 beats/min. A grade 2/6 pansystolic murmur audible at the apex is consistent with moderate mitral insufficiency. The remainder of the cardiopulmonary and neurologic examination results are unremarkable.

Examination of the oral cavity reveals nodularity of the floor of the mouth, with large multilobulated bony hard masses inside the mandible and hard palate (Figure 1). She has symmetrical palatal elevation with an intact gag reflex. No cervical or supraclavicular lymphadenopathy is noted. The thyroid examination reveals a mildly enlarged thyroid gland, with no nodules noted. Her modified Mallampati score is class 4.

Figure 1.

CT of the neck shows multiple exostotic bony lesions within the maxilla, mandible, and floor of the oral cavity (Figures 2 and 3). Her hemoglobin level is 16.5 g/dL (reference range, 11.6-15 g/dL), hematocrit is 47% (reference range, 36% to 48%), and serum bicarbonate level is 37 mEq/L (reference range, 22-29 mEq/L). Her thyroid-stimulating hormone level is 1.83 mU/L (reference range, 0.5-5 mU/L), and her thyroxine level is 7.2 µg/dL (reference range, 5-11 µg/dL).

Figure 2.

Figure 3.


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