Case 1

73-year-old with anemia and mild thrombocytopenia for five months. Workup showed no evidence of blood loss. He is quite fatigued and has lost weight. No fever, jaundice, pruritus, dark-colored urine, bleeding or melena. He recently started taking Hyzaar, but he has had no other recent medication changes.PAST MEDICAL HISTORY:

1. Anemia and mild thrombocytopenia, both recently diagnosed.
2. History of atrial fibrillation.
3. Type 2 diabetes.
4. Hyperlipidemia.
5. Congestive heart failure.
6. Status post tonsillectomy.
7. Status post oral surgery.

MEDICATIONS:

1. Glyburide 5 mg twice daily.
2. Zocor 40 mg daily.
3. Digoxin 0.15 mg daily.
4. Hyzaar daily

SOCIAL HISTORY: He is a retired anesthesiologist, married, 3 children. Former pipe smoker. Drank 2 to 3 glasses of wine daily, but abstinent recently.FAMILY HISTORY: A grandmother had type 2 diabetes. Father had Parkinson disease and Mother died of old age at 94. A sister has asthma, CHF and obesity.REVIEW OF SYSTEMS: He feels tired and weak. He has chronic right shoulder rotator cuff pain. No GU symptoms. He has had anorexia and a 10-pound weight loss over the last couple of months. He has shortness of breath with light activity. He was treated for pneumonia in fall 2003. He has atrial fibrillation, but no chest pain. No neurologic symptoms, rashes, or emotional problems. Had trouble with blood sugar control recently, metformin was discontinued.PHYSICAL EXAMINATION: Somewhat obese. Not appearacutely ill. His sclerae are anicteric. No palpable cervical, supraclavicular, axillary or inguinal adenopathy. The heart rhythm is irregularly irregular. The lungs are clear to auscultation. Abdomen is soft, nontender and nondistended. Spleen is not palpable. The liver is palpable 1 to 2 fingerbreadths below the costal margin. The extremities have trace edema. Neurologic exam shows no focal deficits.