I was working as a paramedic the other day and went on an interfacility transfer with the following:
50 y/o F non-smoker for past 5-7 years and social drinker
Past Hx of numerous kidney stones and unknown arrhythmia (possible SVT) treated with Digoxin.
No Hx of HTN, MI, CVA, Cancer
Being taken to Pittsburgh hospital due to the following:
Numerous Kidney Stones
Calcification of Proximal Aorta
Multiple Nodes in Chest
This all came from the chart
My question: Is there a disease process that can cause all this? Maybe something regarding Calcium?
I was just curious b/c I have never seen or heard of anything like this.
Thanks,
DU
Patients on internal medicine services often present with multiple complaints and may have extensive past medical histories. However, you did not state why the patient was admitted or why they were transfered. All we have is a past medical history and no history of present illness.
Let's look at kidney stones, fairly common, most common metabolic derrangement is excess caclium in the urine. Complex issue, you could read a chapter on kidney stones in a medical textbook. Too large a topic to cover here.
Are all patients with "multiple kidney stones" taken to the hospital? Probably not as some may be small enough to pass on their own.
Let's look at calcification of the aorta and "multiple nodes." Calcification of the aorta is a common finding in older patients, not sure how common in a 50 year old. May be what we call an "incidental and normal finding." Also there are "multiple nodes" this could mean almost anything depending where these lymph nodes are found. For example, multiple nodes in a chest CT in a patient with lung cancer could be lymph nodes infiltrated by cancer.
Or, lymph nodes in the mesentery could be related to an intestinal tract infection, or again malignancy.
The patient might have an arrhythmia, or maybe he/she has CHF and that is what the digoxin is for? The history here is bad. Some patients I have seen confuse CHF with a heart arrhythmia, and they may have both and not realize that the digoxin is for something else entirely.
Remember each patient has a "Chief Complaint" i.e. why are you in the hospital? The patient likely didn't complain of "lymph nodes" in his/her chest so possibly presented with the signs of kidney stones. Often times the "Chief complaint" is wrong, i.e. the internal medicine writes that the chief complaint is for "burning sensation in chest", when perhaps the real reason is that the patient is experiencing increasing fatigue and mistook a history of chronic gastro-esophageal reflux for the why the patient came to the hospital. This is why you have to ask, "What specifically brought you into the hospital day." And sometimes the patient dither about and you have to ask again, "I know that most people don't just come to the hospital as the wait was really long, what made you get out of bed (or leave work) and decide to come to the emergency room." (You have to be really nice when you ask the last one!)
I don't think that the patient is being transfered for something as routine as kidney stones, so there may be another working diagnosis, i.e. malignancy. Some malignancies, i.e. malignant melanoma may lead to kidney stones. We actually don't know what the patient's kidney stones are made of.
The patient may not have a "unifying diagnosis" to link his/her symptoms and radiologic findings, but it could be a malignancy, rare, but possible. You said the patient was a non-smoker for the past 5-7 years, that is confusing. I am guessing that perhaps from 16 years of age to 45 years of age she smoked, how much? If she smoked 3 pack per day for 30 years I would expect to see evidence of COPD on a chest x-ray, and it increases her chances of certain types of cancers, such as lung cancer.
Or, actually sarcoidosis, a multisystem disease, could possibly cause all of the findings. Sarcoidosis often shows as bilateral hilar lymphadenopathy and chest lesions on imaging, so perhaps could account for chest lymph nodes. Although rare, nephrocalcinosis can occur secondary to sarcoidosis, and perhaps 20% of sarcoidosis patients have evidence of renal involvement on autopsy, although 1% have kidney stones secondary to sarcoidosis. Cardiac involvement is more common in sarcoidosis and have seen patients myself with this, certainly a multitude of cardiac brady- and tachyarrhythmia and bundle branch block can be caused by sarcoidosis. Although almost 100% of patients 70 years of age above have calcification of the aorta on imaging, I am uncertain of the percentage of 50 year olds with this finding, as sarcoidosis can cause hypercalcemia, this might have accelerated the process of calcification of her aorta and would prompt me to order a serum calcium level in addition to other labs.
Realize that this information tells us nothing, in medical school you would have to say this is a 50 year old female with a XXX pack-year smoking history who presented X days ago with left sided flank pain. Past Medical history significant for multiple episodes of kidney stones and cardiac arrhythmia per patient, although she doesn't know what type of arrythmia, and is currently on digoxin and no other medications. Patient has a 90 pack year smoking history (if I assume 3 packs per day for 30 years, as an extreme), drinks alcohol once a month, no recreational drug use. Subsequent radiologic workup revealed multiple lymph nodes in the mediastinal region on chest CT and transfered to oncology service for lymph node biopsy. (?)
In terms of social drinking, some people define 3-4 beers a day as social drinking so this comment means nothing in itself.
Even this blurb isn't close to being enough for rounds.
Final Guess (If there is one disease): Systemic Sarcoidosis. If you don't think about it, you'll never diagnose it!
