A 67 year-old male with a past medical history of hypertension and insulin-dependent type II diabetes complicated by neuropathy, retinopathy, and chronic kidney disease presented to the hospital with a complaint of fatigue. The patient noted generalized weakness that had begun the morning of admission after two days of malaise and subjective fever. This weakness prevented him from being able to rise from a sitting position, resulting in a fall off the couch. He denied injury from this fall along with shortness of breath or chest pain, however, he did admit to two episodes of vomiting the day prior to admission.The patient was taking the following medications: furosemide, aspirin, isosorbide mononitrate, lipitor, levothyroxine, candesartan, metoprolol, clopidogrel, doxazosin, calcitriol and Insulin 70/30. Medical history included, hyperlipidemia, hypothyroidism, benign prostatic hypertrophy, stable angina, and peripheral vascular disease along with the conditions listed above. Past surgical history included 2 stents in the LAD coronary artery, vitrectomy, and transurethral resection of the prostate (TURP). Additionally, the patient noted that he lived alone after having retired from teaching and denied any drugs, smoking or alcohol.On physical exam, the patient was febrile at 102.2°F, heart rate was 99, respiratory rate was 17, and blood pressure was elevated at 183/56 mmHg. Generally, the patient was dehydrated and appeared to be somnolent but responsive to questions. Neurological exam was remarkable for generalized bilateral upper and lower extremity weakness and asterixis with no focal neurological deficits. His cranial nerves were intact. Skin exam was significant for a warm, erythematous, blanching, non-pruritic rash on the left anterior tibial surface, as well as an eschar on the 2nd toe of the left foot. The rest of physical exam was within normal limits.An arterial blood gas was performed due to his overall lethargic state and demonstrated a pH of 7.34, PCO2 34, PO2 66 and oxygen saturation of 91% on room air. His electrolytes were Na 134, K 5.3, Cl 106, HCO3 19, significant for a non-anion gap metabolic acidosis with a compensatory respiratory alkalosis. Glucose was elevated at 412mg/dl. Additional laboratory values revealed a BUN of 79 and creatinine of 3.1 (previous baseline of 2.3). Urine studies showed protein >300 mg/dl, urine pH of 5.5, urine glucose 500, and rare hyaline casts. Urine electrolytes results included Na 49, K 30.2, Cl 54, and Cr of 98.7. Lactate was within normal limits.The patient was treated acutely for dehydration and hyperglycemia with intravenous fluids and insulin. He was started on broad spectrum antibiotics for suspected cellulitis and osteomyelitis of the 2nd left toe. The combined results of the urine anion gap of + 25.2, the serum anion gap of 9, and hyperkalemia led us to a preliminary diagnosis of renal tubular acidosis type IV. Finally, the renin level returned low at 1.4 ng/ mL/hr (normal 1.9-3.7) indicating a low renin -low aldosterone as an underlying cause of the met...

A 19-year-old man with no past medical history presented to the ER with a sore throat, cough, and pleuritic chest pain. The patient had been well until 1 month before admission, when he developed a sore throat and felt ill. He presented to the emergency department twice for these symptoms. On the first visit, the patient had a positive rapid strep test. He was diagnosed with strep throat and treated with penicillin IM. However, his sore throat persisted. Five days before admission, the patient developed a non-productive cough. One day prior to admission he developed severe right sided chest pain that was throbbing, pleuritic, and radiated to his right shoulder. The pain, which was initially relieved by sitting forward and with Ibuprofen, continued to worsen, prompting the patient's mother to bring him back to be re-evaluated.Upon presentation, the patient denied shortness of breath, fevers, or chills. He had no personal history of prenatal or childhood disease, and denied family history of early heart disease, lung disease, cancer or bleeding disorders. He denied tobacco, alcohol, or illicit drug use. He reported being heterosexual with 4-5 lifetime sexual partners, and one new partner in the prior two months.On examination, the patient was a well nourished, well developed, young African American man in moderate distress. The blood pressure was 117/57, heart rate 66, respiratory rate 16, oxygen saturation 98% on 2 L nasal cannula and temperature 37.5ºC. The physical exam was remarkable only for slight pharyngeal erythema and enlarged, non-purulent tonsils. His heart was without murmurs, rubs, or gallops. His lungs were clear to auscultation bilaterally. Initial labwork was unremarkable, with a normal white blood cell count. A chest radiograph revealed findings in the right lower lobe concerning for subsegmental atelectasis versus consolidation. Electrocardiogram demonstrated an incomplete right bundle branch block. A thoracic CT demonstrated a large right lower lobe pulmonary embolism with an associated area of pulmonary infarction.Given the finding of the patient's pulmonary embolism, our top three differential diagnoses were a primary underlying hypercoagulable state, an infection predisposing the patient to a hypercoaguable state, or an underlying malignancy. The patient was admitted to the hospital, blood work was drawn, and he was started on Warfarin with an Enoxaparin bridge. During his work up, the patient was found to have elevated antistreptolysin O titers, consistent with a prior streptococcus infection. Blood cultures were negative. In addition, HIV, HSV, gonorrhea, chlamydia, group A strep, and H1N1 PCR were all negative. CT of the abdomen and pelvis and testicular ultrasound were normal, without any signs of malignancy. A rheumatologic workup, including an anti-nuclear antibody and anti-neutrophil cytoplasmic antibody were negative. A hypercoagulable work up was sent prior to initiation of anticoagulation therapy. Protein C, protein S, factor V leiden, antithrombin III, and anticardiolipin antibodie...