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A 56-Year-Old Woman With Subacute Onset of Severe Constitutional Symptoms, Part 2

Ronald N. Rubin, MD1,2 Series Editor

  • A 56-year-old woman presented to the emergency room due to an alteration in mental status. The family reported that in recent weeks she became distracted, lethargic, and drowsy at times with reduced alertness in recent days. The family also noted that while she generally has weakness, she can move her extremities and she can speak when sufficiently aroused. Although she was urinating often, she felt constipated and was regularly thirsty.

    Patient history. The patient’s medical history was negative for both hypertension and diabetes. She was diagnosed with node positive Stage II breast carcinoma 2 years prior and was treated with lumpectomy, local irradiation, and adjuvant chemotherapy. Her most recent follow-up was 5 months ago.

    Physical examination. On physical examination, the patient appeared quite ill, but she was afebrile. She was drowsy but could be awakened when necessary. Her heart rate was 104 beats per minute with a blood pressure of 96/64 supine. Her mucosae were parched, and her skin turgor pointed to significant dehydration. There were several stony-hard lymph nodes in the left axillae, which was where her breast cancer presented. Her neurological examination was negative for lateralizing signs. She had reduced alertness but was arousable and disoriented to time and place. The examination also showed diffuse sluggishness of reflexes.

    Diagnostic testing. The patient’s initial laboratory tests included a complete blood count with hemoglobin of 16 gms/dL, which was within normal range. Her serum sodium level was 132 mEq/L (signifying mild hyponatremia). While her serum creatinine was elevated (3.0 mg/dL). Although her albumin of 3.0 gms/dL was slightly below normal range, her serum calcium 15.9 mg/dL was elevated. The paitent’s serum phosphorous levels were within normal limits.

    (Answer and discussion on the next page).