โ Scribed by Richard O Shields Jr
No coin nor oath required. For personal study only.
Dr Olson: The patient is a 3t-year-old urban black man in excellent health until five days prior to emergency admission, when he noted the onset of severe rnyalgia and headache after exertion at work. He went to another hos~ pital where scleral icterus was noted. Despite a bilirubin of 17.2 rng%, blood urea nitrogen of 41 mg% and creatinine of 4.6 mg%, the patient refused admission.
Two days later he presented to the Milwaukee Regional Medical Center Emergency Department with continued myalgias, headache, stiff neck, light stools, dark urine, pruritus, and anorexia. He denied fever or chills, emesis, diarrhea, illness in .the family, military service, foreign travel, or pet exposure.
His job involved working in a warehoue with roofing tar. None of his coworkers had similar symptoms. There was no history of gall bladder disease, peptic ulcer, Or weight loss. One niece, the daughter of a sister, had sickle cell anemia.
He denied alcohol and intravenous drug use, although he has had subsequent admissions to alcohol detoxification units.
On examination he was noted to be a muscular young man with photophobia, jaundice, and mild lethargy. Temperature was 98.6 ยฃ; pulse, 110/ minute and regular; respirations, 16/minute; and blood pressure, 108/60 mm Hg. There was scleral icterus without conjunctival injection. His neck was supple. Several small lymph nodes were present in both axillae. The lungs were clear and heart sounds were normal. There was no hepatosplenornegaly or abdominal bruits, and stool examination was negative for occult blood. There were no rectal masses. The paraspinal, deltoid, latissirnus dorsi, and quadricep muscles were tender. There was no muscle fasciculation, atrophy, or joint effusions.
He was oriented and coherent, and his neurologic examination was within normal limits.
Hemoglobin was 11.7 gm%; hematocrit, 85; mean corpuscular volume, 84; and platelets, lll,000/rnm 3. The white blood count was 14,000/mm 3, with 86%segmented forms, 3% bands, 2% lyrnphocytes, and 9% monocytes.
Prothrornbin and partial thromboplastin times were normal. Sedimentation rate was 115 mm/hour, and the sickle cell prep was positive. Glucose
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