Bedside Diagnostic Challenge – 24-year-old woman with weakness

Paul Griner, MD, MACPBedside Diagnostic Challenge, Internal Medicine

Test your bedside diagnostic skills with this free clinical case question.

Case

A 24-year-old woman presents with the complaints of general weakness, depression and aching of her large joints for the last few months. These symptoms began insidiously but have become progressively more pronounced over the past few weeks. The aching joints are somewhat relieved by 6-8 acetaminophen per day.

She takes no other medications; she drinks a beer once or twice a week, does not smoke, and denies use of illicit drugs.

She works as a secretary at a large company and indicates that her symptoms have reduced her productivity. She states that one of her cousins has Wilson’s disease and that arthritis “runs in the family.”

Physical examination reveals a woman of stated age whose finger nails and mucus membranes are pale.

Temperature is 99.20 F, Blood pressure is 115/70 mm Hg, Pulse is 92 and regular and respirations are 16/minute.

Abnormal findings include a palpable, non-tender liver 3 cm below the right costal margin, and palpable spleen just below the left costal margin. Otherwise, the abdomen is soft and non-tender.

There are no abnormal findings on examination of the musculoskeletal system, the eyes or the neurologic system.

Laboratory studies:

  • Hemoglobin 8 gm/L
  • Hematocrit 25 %
  • Blood smear abundant spherocytes and poikilocytes
  • Reticulocyte count 4.2%
  • Coombs test negative
  • White blood cell count 6,500/mm3
  • Platelet count 340,000/mm3
  • Urinalysis normal
  • Bilirubin 2.6 mg/dL
  • Aspartate aminotransferase  1,720 U/L
  • Alkaline phosphatase 249 U/L

Normal Laboratory Values

Question

Based on the diagnostic value of careful examination …

These findings suggest a diagnosis of:

Answer Options:

Hemochromatosis

Wilson’s disease

Hereditary spherocytosis

Drug induced hepatitis

Answer Explanation & References:


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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.