Wednesday, April 18, 2012

Different symptoms with the same diagnosis. This could happen to you?

I will present 2 cases of patients with pre-diabetes , mild hypertension , dyslipidemia who have very different symptoms of the same medical problem.

Case #1 72 y/o male with a  Fasting blood glucose of 116 mg/dl, A1c of 6.1,
                                              Blood Pressure 126/78
                                              Cholesterol 116
                                              LDL             57
                                              triglyceride 114
                                              HDL            36

Medications  zocor  ( simvastatin )           20 mg/day for  2 years
                      lisinopril                              20 mg/day  for 3 years
                      metformin                          500 mg twice daily
                      aspirin                                  85mg/day
                      omega -3 FA                     960 mg twice daily

Symptoms .  recurrent episodes , separated by weeks or months , of a stinging sensation followed by itching and swelling of the top of his right or left foot . The swelling and itching would subside over the next 4 to 5 days and he would be asymptomatic until the next episode. He attributed the symptoms to  insect bites.
One afternoon while watching TV he developed a numb tingling swelling sensation in the left half of his tongue that lasted about 1 hour. The tongue symptoms prompted a doctor visit .

A diagnosis was made , treatment was started with complete resolution of all symptoms.

What is your diagnosis ?

Case #2  71 y/o female with a : Fasting glucose of  112
                                                  Blood Pressure       132/86
                                                  Cholesterol             168 mg/dl
                                                  LDL                         66 mg/dl
                                                  HDL                         52 mg/dl
                                                  Triglycerides           249 mg/dl
  Medications        Zocor  (simvastatin )                     40 mg/day for years
                              Omega -3 -Fatty Acid               4000 mg/day for years
                               Lisinopril                                      40 mg/day for years
                               coumadin                                        5 mg/day for 3 years


     The sudden onset of  severe chest pain , nausea , sweating and difficulty breathing. The symptoms subsided in the emergency room. Her physical exam , EKG, chest x ray and test for heart damage was normal. They did find 3 abnormal liver test.  She had similar symptoms about 15 years ago which resulted in a diagnosis of gall bladder disease and surgery.She had repeat liver test the next week that were normal.She saw a cardiologist who could not find any evidence of heart disease. She continued to have the same recurrent symptoms , multiple Emergency room visits. Abnormal liver test that quickly returned to normal were present with each episode of pain . She was referred to a gastroenterologist to for further evaluation and to rule out a retained gall stone. After the visit and plans for further invasive studies  were discussed . A doctor friend suggested a unusual  possible diagnosis.  Treatment was initiated  with complete resolution of her symptoms.

What is your diagnosis ? 
Are these 2 cases the result of the same problem?
The clue to the diagnosis of both cases is discussed above.

Have Fun  Be Smart and make a diagnosis and don't overlook these symptoms.
This could happen to you

The answer and discussion tomorrow.

David Calder, MD



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Your comments and questions are appreciated. David Calder,MD