Rules for August 2008 Race Case

1. The goal is to determine the correct diagnosis in the shortest amount of time. Each team can submit only one answer.

2. A team may answer at any time. This case has information distributed at time 0, 10, 15 and 20 minutes.

3. A team can consist of residents and students only. Chief residents, fellows, and attendings may watch, but they are not allowed to participate.

4. No PDA, book, or computer help is allowed. Team members must use sheer brain power alone.

5. Chief Residents are responsible for distributing the envelopes of information at the correct times and for providing the results to the tests requested as part of the second envelope of information.

6. Chief Residents are responsible for recording start and stop times (or total elapsed time during the case). Chiefs should email these times along with the team’s answer for the diagnosis to Shane O’Mahony at [email protected].

7. After a team has submitted its answer, the team may watch the discussion provided on windows media player file (19 minutes).

The winning team will be announced later in the day. The winning team will assume care of Ronald the Gnome and will have breakfast provided at report later in the week. ID/CC: 51 yo man presented with fevers, chills, nightsweats, and headache for 5 days.

HPI: The patient was in his usual state of good health when 5 days PTA he developed acute onset of fever, chills, night sweats and headache after returning to Southeastern Alaska from a trip to Oregon. He was evaluated by a care provider and was initially thought to have the flu. His HA and febrile symptoms persisted and one-day PTA he subsequently developed a nonproductive cough without hemoptysis. He was then seen by another provider in Alaska who requested that the patient be admitted to the UW for further evaluation.

The patient had returned to Alaska from a trip to the Oregon coast and MacKenzie River/Eugene area on the day that the fever began. He had hiked in Coastal Woods, drank only bottled water, and swept a cabin in Mackenzie River, Oregon. Prior to traveling to Oregon, he had been on a rabbit hunting trip in Alaska. He has 2 dogs and 3 cats in good health. No birds. No sick human contacts. He had a negative PPD 10 months prior when several persons in his home village developed TB.

ROS: He denied any weight loss, arthralgias, rashes, and hemoptysis. No URI symptoms or sore throat.

PMH: Borderline HTN Gout

PSH: Remote knee surgery Remote shoulder surgery Social History: Hernia repair Married fourth grade teacher from Kake, Alaska. Allergies: Lives on a float house on the waterfront. NKDA No IVDU 1-2 beers QD Medications: Past hx of chewing tobacco and cigarette Allopurinol use. Grapeseed extract MVI Family History Chrondroitin Father with h/o CAD and osteoarthritis. Glucosamine Mother with unclear kidney problems Physical Exam T 38.0 BP 153/92 P 103 RR 22 O2sat 98 % on RA GEN: ill appearing, diaphoretic male EYES: sclera anicteric, no papilledema ENT: no oral ulceration RESP: CTA with normal effort CV: tachycardic, no m/r/g GI: abdomen obese soft, NT, ND, hypoactive bowel sounds, no hepatomegaly, no fluid wave or bulging flanks Skin: no LAD, no rash Neuro: A&O x 3, strength 5/5 throughout with 2+ reflexes on the UE and LE bilaterally, toes downgoing, intact cranial nerves

LABS 132 / 102 / 28 INR 1.2 4.6 / 26 / 1.4 PTT 55 Glucose 123 Fibrinogen 759 Ca 8.0 ESR 88

WBC 7.1 AST 27 PMN 6.05 ALT 24 Lymph 0.37 Mono 0.81 AlkP 63 Eos 0 Bili 0.7 Baso 0.15 Hct 33% MCV 81 Alb 3.4 Plt 366K LDH 347 ( normal <198) Uric acid 9.5 (normal 3.4-7.8) Cultures Sputum – 4+ micrococcus, 4+ viridans strep, 2+ coag neg Staph, 2+ Haemophilus, 3+ Stomatococcus Urine Cx – Neg Blood Cx – Neg

Imaging: CXR – small L pleural effusion, enlarged hilum CT chest – lingular consolidation, small to moderate pleural effusion on left, hilar adenopathy present but less than 1cm, enlarged spleen, normal liver TO BE GIVEN OUT AT TEN MINUTES

The patient is placed on a 3rd generation cephalosporin and a macrolide but he continues to have fevers and worsening respiratory symptoms.

Monospot, ANA, RF, ANCA, HIV, RPR– all normal Hepatitis serologies showed evidence of past Hep A and Hep B. HCV negative.

Pleural Fluid LDH 2729 87% lymphocytes no organisms on gram stain TO BE GIVEN OUT AT 15 MINUTES

The patient is transferred to the ICU for respiratory distress. Ciprofloxacin is added to the antibiotic regimen.

Serologies for Brucella are negative. Bronchoscopy lavage - 13,000 col/ml viridans Strep: at least 3 colony types; 800 col/ml Coag Neg Staph; 1500 col/ml Non hemolytic Strep sp, not enterococcus TO BE GIVEN OUT AT 20 MINUTES

The fevers have abated and the patient has improvement in his respiratory status.

Pleural fluid returns with growth of a fastidious gram negative coccobacillus and the lab is notified to take precautions to prevent transmission. The State Health Department is notified. Serologies for the same agent return positive. Kake, Alaska