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Clinical Pathological Conference

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Clinical Pathological Conference Powered By Docstoc
					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
EKG, sinus tachycardia
Abdominal/pelvic CT with
      IV contrast
Abdominal/pelvic CT
A DIAGNOSTIC PROCEDURE
     WAS PERFORMED

				
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