Download Clinical Pathological Conference

Clinical Pathological
Conference
Elizabeth Ross, M.D.
 Chief Resident
Department of Medicine
 October 12th, 2007
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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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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
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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
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Monthly, regular menstruation since
menarche, with heavy bleeding
Physical Exam
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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
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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
34.9

MCV 85 (80-100)
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
4.6
26
0.5
Ca 8.0
Mg 1.7
Phos 2.0
Chemistry/Serology
311
129
193
LDH – 783 (110-225)
ANA – positive
Hep Bs Ab – positive
Hep Bs Ag – negative
Hep Bc Ab – positive
Hep C Ab – negative
6.8
6.0
4.3
3.0
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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