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Clinical Pathological Conference. Elizabeth Ross, M.D. Chief Resident Department of Medicine October 12 th , 2007. Chief Complaint. A 46 year old Dominican woman presents with 3 months of increasing abdominal distention and one month of diffuse epigastric pain. History of Present Illness.
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Clinical Pathological Conference • Elizabeth Ross, M.D. • Chief Resident • Department of Medicine • October 12th, 2007
Chief Complaint • A 46 year old Dominican woman presents with 3 months of increasing abdominal distention and one month of diffuse epigastric pain
History of Present Illness • 2-3 years prior to admission: patient first noticed easy bruisability, she was diagnosed with “anemia” and iron supplementation was started. • 3 months pta: she noticed abdominal distention and was started on a “water pill”. • 1-2 months pta: Her abdominal distention progressed, she felt like she looked pregnant. • 2-3 weeks pta: unrelenting diffuse epigastric pain and discomfort.
HPI, continued • Her pain persisted so she sought medical attention and was admitted to an outside hospital • Imaging and lab studies revealed abnormal LFTs and portal and splenic vein thrombosis • She was started on a heparin drip and transferred to Bellevue • Repeat imaging confirmed IVC and hepatic vein thrombosis and also showed portal and splenic vein thrombosis
Additonal History Past Medical History: As above Past Surg History: Tuboligation 15 years ago Medications: iron, multivitamin On transfer: heparin drip Allergies: none Family History: Denies history of: clotting disorders, bleeding disorders, malignancy Social History: Born in Dominican Republic, has lived in the US for 10 years, no recent travel. Ten pack-year tobacco history, quit 9 years ago. No etoh, no illicit drug use. Lives with husband. Worked as HHA until four months ago.
Review of Symptoms • Monthly, regular menstruation since menarche, with heavy bleeding
Physical Exam • General: well-developed woman with apparent ascites, moaning in pain, appears stated age, mildly jaundice • Vital signs: BP 127/82, HR 108 and regular, RR 18, Temp 97.6, SpO2 97% room air • HEENT: oropharynx dry, mild scleral icterus • Lymph: no cervical, axillary or inguinal lymphadenopathy • Neck: supple, no jugular venous distension • Pulmonary: clear to auscultation bilaterally
Physical Exam, continued • Heart: tachycardic, regular rhythm, normal heart sounds, no murmurs • Abdominal: Distended, diffusely tender, shifting dullness present, fluid wave present, no masses palpable • Extremities: trace lower extremity edema bilaterally, 2+ peripheral pulses • Skin: no rashes • Rectal: guaiac negative • Neuro: Alert and oriented to person, place and time • Asterixis present
Hematology 11.7 9.3 59 MCV 85 (80-100) 34.9 MPV 9.9 (7.4-10.4) • Differential - wnl INR 1.67, PT 21, PTT 66 HIT Antibody – Positive Thrombin Time 133.6 (21.5 –29.9) RVVT – No Inhibitor Detected
Chemistry 130 95 13 90 Ca 8.0 4.6 26 0.5 Mg 1.7 Phos 2.0
Chemistry/Serology 311 129 6.8 6.0 193 4.3 3.0 LDH – 783 (110-225) ANA – positive Hep Bs Ab – positive Hep Bs Ag – negative Hep Bc Ab – positive Hep C Ab – negative
Urinalysis: • orange colored, clear; no glucose, moderate (2+) bilirubin, no ketones, Specific gravity 1.048, trace blood, trace protein, pH 6.5, Urobilinogen 4.0 eu/dL (0-2), no nitrite, trace leukocyte esterase, WBC 0-2, RBC 0-2
