Cases from the Osler medical service at Johns Hopkins University

Catherine Passaretti, Aimee Zaas

Research output: Contribution to journalArticle

Abstract

Presenting features A 56-year-old black woman with diabetes mellitus was admitted for hypoglycemia and confusion. Her past medical history included breast cancer, for which she had undergone a left lumpectomy and then mastectomy for in-breast recurrence. Her oral intake had decreased during the past month because of increasing discomfort from left-sided chest pain. During this period, she continued to take pioglitazone for diabetes at her originally prescribed dose. The patient's mental status improved quickly after taking orange juice and intravenous glucose, but the chest pain persisted. The pain, which was described as an ache along the left costal margin, increased with palpation, deep inspiration, or coughing. She had recently presented with similar complaints at another hospital where she had been prescribed a muscle relaxant that provided no relief from the pain. She also reported a 14-lb weight loss during the previous 3 months, as well as fatigue, weakness, and aches in her legs and arms. She denied fevers, chills, sweats, abdominal pain, nausea, or recent trauma. Laboratory values at the time of admission were: calcium, 11.8 mg/dL; total protein, 11.1 mg/dL; albumin, 3.2 g/dL; creatinine, 1.0 mg/dL; and hematocrit, 29.3%, with a mean corpuscular volume of 89.3. Chest radiography revealed a lytic lesion in the left lateral fourth rib and left humerus (Figure 1). Serum and urine protein electrophoresis revealed a monoclonal spike in the gamma region consistent with monoclonal gammopathy. The serum spike was quantified at 3.78 g/dL. A skeletal survey showed many small well-defined lytic lesions in the skull (with one 1.5-cm lytic lesion in the upper posterior parietal bone), arms, and legs. A bone scan showed multiple foci of increased uptake in the right and left ribs as well as the proximal portion of the left femur. The peripheral blood smear revealed rouleaux formation (Figure 2) and plasma cells (Figure 3). What is the diagnosis?

Original languageEnglish (US)
Pages (from-to)613-616
Number of pages4
JournalAmerican Journal of Medicine
Volume114
Issue number7
DOIs
StatePublished - May 2003
Externally publishedYes

Fingerprint

Pain
pioglitazone
Ribs
Chest Pain
Arm Bones
Leg Bones
Parietal Bone
Confusion
Chills
Paraproteinemias
Erythrocyte Indices
Segmental Mastectomy
Sweat
Palpation
Mastectomy
Humerus
Mentally Ill Persons
Plasma Cells
Hematocrit
Hypoglycemia

ASJC Scopus subject areas

  • Nursing(all)

Cite this

Cases from the Osler medical service at Johns Hopkins University. / Passaretti, Catherine; Zaas, Aimee.

In: American Journal of Medicine, Vol. 114, No. 7, 05.2003, p. 613-616.

Research output: Contribution to journalArticle

Passaretti, Catherine ; Zaas, Aimee. / Cases from the Osler medical service at Johns Hopkins University. In: American Journal of Medicine. 2003 ; Vol. 114, No. 7. pp. 613-616.
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