A School Nurse With Anxiety, Diarrhea, Palpitations, and Cough

Jennifer Wachala, DO; Dushyant Singh Dahiya, MD; Farah Wani, MD; Asim Kichloo, MD


April 19, 2022

Physical Examination and Workup

Upon examination, the patient appears comfortable and is in no acute distress. Her mucous membranes and skin are dry. She has a temperature of 99.8 °F (37.7 °C), a heart rate of 118 beats/min, a blood pressure of 139/82 mm Hg, and a respiration rate of 20 breaths/min, with an oxygen saturation of 95% on room air. Her body mass index is 29.

Her neck is supple, and no thyromegaly or lymphadenopathy is noted. The cardiac examination reveals a regular rate, tachycardia, and normal S1 and S2 heart sounds, without murmurs, rubs, or gallops. The lungs are clear to auscultation bilaterally, and no wheezing, rales, or rhonchi are detected. The abdominal examination reveals moderate tenderness with deep palpation in the right and left lower quadrants and diffuse hyperactive bowel sounds. No masses or hernia, abdominal distention, or hepatosplenomegaly is noted. The neurologic examination reveals 5/5 strength in all extremities, intact sensations, and no deficits in cranial nerves III-XII.

Laboratory investigations show the following values:

  • Hemoglobin level: 12 g/dL (reference range, 12-16 g/dL)

  • Hematocrit: 40% (reference range, 36%-46%)

  • Platelet count: 352 × 103 cells/µL (reference range, 150-400 × 103 cells/µL)

  • White blood cell count: 4000 cells/µL (reference range, 4000-11,000 cells/µL) with 74% neutrophils (reference range, 55%-70%)

Results of a basic metabolic panel are as follows:

  • Sodium level: 133 mmol/L (reference range, 135-147 mmol/L)

  • Potassium level: 3.4 mmol/L (reference range, 3.5-5.0 mmol/L)

  • Chloride level: 92 mmol/L (reference range, 98-106 mmol/L)

  • Bicarbonate level: 38 mmol/L (reference range, 22-30 mmol/L)

  • Blood urea nitrogen level: 38 mg/dL (reference range, 8-21 mg/dL)

  • Creatinine level: 0.87 mg/dL (reference range, 0.5-1.1 mg/dL)

  • Fasting glucose level: 112 mg/dL (reference range, 70-100 mg/dL)

  • Magnesium level: 1.7 mmol/L (reference range, 0.65-1.05 mmol/L)

Liver function test results are within normal limits. The D-dimer level is 260 ng/mL (reference range, < 250 ng/mL); the ferritin level is 500 µg/L (reference range, 11-307 µg/L); and the C-reactive protein level is 1.20 mg/L (reference range, 0-10 mg/L). An ECG demonstrates sinus rhythm, with a heart rate of 120 beats/min and a QTc of 359 msec. A chest radiograph is obtained. The findings are similar to those shown in the Figure. CT of the abdomen and pelvis is also performed, and the results are pending.

Figure 1.


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