July 2021 – Presented by Dr. Alison Chan (Mentored by Dr. Sarah Barnhard)
Clinical History
The patient is a 46-year-old man with a history of Lupus and hypothyroidism who presented to the hospital after suddenly developing expressive aphasia where he began “speaking gibberish”. He is being treated for Lupus by a doctor in Mexico. He has no history of tobacco, alcohol, or illicit drug use.
Vital signs were heart rate 101, respirations 14, blood pressure 144/74, and temperature 39C (102.2F).
Initial physical exam findings showed that the patient is alert and awake. Patient is lucid and able to follow commands. He had no additional neurologic deficits aside from expressive aphasia. There was petechiae noted around his right upper extremity under the blood pressure cuff. The remaining physical exam is unremarkable. A head CT showed no evidence of infarct or hemorrhage. While waiting for the brain MRI, his neurologic status began to deteriorate.
Labs
Chemistry Panel
| Patient | Reference | |
| Sodium | 135 | 135 - 145 |
| Potassium | 3.7 | 3.3 - 5.0 |
| Chloride | 107 | 95 - 110 |
| Carbon dioxide total | 20 | 24 - 32 |
| Urea nitrogen | 23 | 8 - 22 |
| Creatinine Blood | 1.43 | 0.44 – 1.27 |
| Glucose | 87 | 70 - 99 |
| Calcium | 7.3 | 8.6 – 10.5 |
| Bilirubin total | 1.9 | 0.3 – 1.3 |
| Lactate dehydrogenase | 552 | 90 - 200 |
| Haptoglobin | 6 | 10 - 210 |
Complete Blood Count
| Patient | Reference | |
| White blood cell count | 4.0 | 4.5 – 11.0 |
| Red blood cell count | 2.76 | 4.5 – 5.9 |
| Hemoglobin | 8.2 | 14 – 18 |
| Hematocrit | 23.8 | 40 - 52 |
| MCV | 86.3 | 80 - 100 |
| MCH | 29.8 | 27 - 33 |
| MCHC | 34.5 | 32 - 36 |
| RDW | 16.1 | 0 – 14.7 |
| Platelet count | 38 | 130 - 400 |
| MPV | 7.5 | 6.8 - 10 |
Peripheral Blood Smear:
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