Ms. A.b, 29 years old, female, married, G2P2, Filipino, Roman Catholic, resident of Cebu City, admitted for the 2nd time in Hospital X for abdominal enlargement.
History:
Six months prior to admission:
- non-bloody, watery stools (1-2 episodes/day; 50 cc/episode)
- no consult done
- no medications taken
Five months prior to admission:
- Persistence of symptoms
- Abdominal pain (prickling, intermittent without precipitating cause)
- Gradual increase in abdominal girth
- Easy fatigability
- 2-pillow orthopnea
- Consult was done and nizatidine was given with other unrecalled medications
Four months prior to admission:
- increasing severity of easy fatigability
- enlarge abdomen
- consult was done at the ER and was subsequently admitted
- Laboratory done: anemia and hypoalbuminemia
- Abdominal and pelvic U/S and Barium enema 鈥?negative findings
- Spironolactone, furosemide, and essentiale were given and transfusion of 2 units of packed red blood cells
- Relief of symptoms
- Patient lost to follow-up
Three weeks prior to admission:
- abdominal discomfort
- abdominal enlargement
- anorexia
- Rapid weight loss (about 25%)
One week prior to admission:
- persistence of above symptoms
- increasing abdominal girth
- progressive episodes of dyspnea
- episodes of diarrhea (soft stools amounting 陆 cup/ episode; 2-3 times daily)
- tea colored urine
- no consult done
- no medications taken
Few hours prior to admission:
- Severe progressive dyspnea
- Consult at ER
Past Medical History
(-) Hypertension, DM, asthma, allergies and TB
Admitted for childbirth and 4 months PTA for same problems
Family History
(+) Hypertension 鈥?both parents; (-) DM, asthma, malignancies
Personal/Social History
Non-smoker, non-alcoholic beverage drinker
OB-GYN History
G2P2 (2002)
G1 鈥?1990, unremarkable
G2 鈥?March 2003, unremarkable
No menses for the past 5 months.
Previously on oral contraceptive pills then shifted to injectable contraceptive.
Physical Examination
Conscious, coherent, stretcher-borne
BP: 100/60 mmHg HR: 89 bpm RR: 22cpm T: 37C
HEENT: Pale palpebral conjunctivae, anicteric sclerae
Neck: Supple, (-) neck vein engorgement, (-) cervical lymphadenopathy
C/L: Symmetrical chest expansion, no retractions, clear breath sounds
CVS: Adynamic precordium, AB 5th LICS, MCL, regular rate, normal rhythm, no murmur
Abdomen: Globular, NABS, soft, non-tender, (+) palpable mass at the LUQ, firm, fixed extending to the R paraumbilical area
Extremity: (+) grade 2 bipedal edema
Course in the ward鈥?br>
First hospital day:
- Spironolactone, aminoleban, ceftriaxone and vit. K were initially given.
- Initial lab: anemia and leukocytosis with hyponatremia, hypoalbuminemia
- Blood transfusion with 2 units of packed red blood cells.
- Fecalysis 鈥?no parasites/ova seen
- Chest x-ray 鈥?normal.
Second hospital day:
- paracentesis of ascetic fluid 鈥?leukocytosis with predominance of segementers
- Repeat abdominal U/S 鈥?diffuse chronic liver parenchymal disease with normal sized spleen and massive ascites. Gallbladder, pancreas, kidneys and urinary bladder were normal.
Third hospital stay:
- Increased abdominal girth accompanied by dyspnea
- Decrease in breath sounds over the Right lung field
- Furoseminde was started
- Repeat CXR 鈥?pleural effusion over the Right lung field
- Repeat paracentesis
- Thoracentesis was contemplated, however, patient could not tolerate an upright position
- ABG 鈥?metabolic acidosis with low bicarbonate levels
- Sodium bicarbonate was started
Fourth hospital day:
- patient develop hypotension (BP: 80/60 mmHg)
- Improved with Dextran
Fifth hospital day:
- Again, hypotension developed refractory to dextran
- Dopamine drip was started
- Few hours later: progressive episodes of dyspnea prompting intubation
- Patient went into cardiac arrest and expired!
LABORATORY RESULTS
CBC 1st HD 2nd HD 3rd HD 4th HD
Hgb 8.2 12.1 10.0
Hct 0.28 0.38 0.31
RBC 4.6 5.6 4.7
WBC 13.5 11.2 14.1
Segs 0.77 0.70 0.85
Lymph 0.16 0.21 0.09
Eos 0.02 0.02 0.01
Mono 0.05 0.07 0.04
Stabs 0.01
Platelets 890 749 239
Retic Count 2.83
BT (1-5鈥? 2鈥?0鈥?
CT(1-5鈥? 3鈥?0鈥?
PT (10-13.6) 12.7 secs 19.2 secs
PTT(31.2-42.2) 39.2 secs 54.0
% Act (76-114) 84.7% 44.5%
INR 1.10 1.71
Blood Chem 1st HD 2nd HD 3rd HD 4th HD
Na 135 meq/L 118
K (3.5-5.1) 3.5 meq/L 3.7 3.8
RBS 129 mg/dL 77.4
BUN (1.7-8.3) 3.4 mmol/L 6.3
Crea (53-115) 48 mmol/L 100
AST (0-31) 30.7 u/L 73
ALT (0-32) 41.9 u/L 43
Alk Phos (50-136) 106 ug/L 831
Total protein (66-87) 62.6 64 63
Albumin (38-51) 23.7 30 28 21
A/G ratio (0.5-2.5:1) 0.6:1 0.9:1 0.8:1 0.7:1
Cholesterol 6.0
Triglycerides 4.5
HDL (1.16-1.68) 0.2
LDL 3.8
URINALYSIS 1st HD 3rd HD
Color/Transparency Yellow/Clear
pH/Sp.Gr. 6.0/1.030
Protein Negative
Sugar Negative
RBC 0-1
WBC 0-1
Epith Cells Few
Uric Acid Occasional
Bacteria Few
FECALYSIS
Color/Consistency Yellow/soft Greenish-b...
Occult blood Negative
WBC Occasional
RBC Few
Microscopy Negative Negative
HEPATITIS PROFILE
HBsAg Non-reactive
Anti-HBs Non-reactive
HBeAg Non-reactive
Anti-HBe Non-reactive
Anti-HBc IgM Non-reactive
Anti-HBc IgG Reactive
Anti-HAV IgM Non-reactive
Anti-HAV IgG Reactive
Anti-HCV Non-reactive
Peripheral Blood Smear:
RBC: mild microcytosis, anisocytosis, and hypochromia with polychromasia
WBC: Moderate shift to the left, no abnormal cells
Adequate platelets
Peritoneal Fluid
Culture: No growth after 2 days
Cell count
Color: Yellow Lymph: 40%
Transparency: turbid Mono: 1%
Total WBC: 1,728 cells/uL Total cell count: 8,532 cells/uL
Segs: 59% RBC count: 6,804 cells/uL
Abdominal ultrasound
Normal gallbladder, pancreas, spleen, and kidneys, urinary bladder
Diffuse chronic parenchymal liver disease, Top normal-sized spleen
Massive ascities
Pelvic ultrasound: Normal uterus and adnexa
Transvaginal ultrasound: Normal-sized uterus and adnexa; normal ovaries; ascites
Abdomen, Barium enema: Essentially negative findings
-end-
Answer the following questions.
1. based on the history, physical examination on admission
1. what could be your impression or working diagnosis?
Support your impression.
2. What could be two other differential diagnoses?
Support.
3. What laboratory tests or procedures would you order?
Why?
2. Interpret the course in the ward and he laboratory tests results of the patient.
Knowing this, would you still stick with your impression or working diagnosis?
If you do not agree anymore with your first impression, which differential diagnosis would you now consider? Or, would you have other differential diagnoses that were not considered during admission?
3. Support and discuss your final diagnosis. actually the lab result are in a table form but they can't be aligne. HD means Hospital day. Like each value is under a hospital day...like 1st 2nd or 3rd... Heaven help us if your in med school asking a bunch of laymen for help on your homework.
I'd hate to be admitted to the ER and wait for your diagnosis after you checked the Internet. a good doctor would consult with other doctors in the hospital not someone on yahoo answers.
OY!!! get a clue man!!!! Seriously man, you'd be better off doing these cases yourself. I learn far better by doing them than just studying. It's more fun too. Don't get too stressed out about med school... there are far more important things in life. Since the pt expired you are better off performing an autopsy and find out the underlying cause of death. i'd say she was sick....think of something weird and rare....parasite,thyphoid,viral
,etc.
something w/liver,infection,lupus,
,lymphoma,also,no perods for 5 months is puzzle. |
