This case has been anonymised for the safety of patient confidentiality and it is reported here for the teaching of Problem Based Learning.
This 74 year old lady was admitted with a history of increasing abdominal swelling and dyspnoea. The abdominal swelling started 3 months before and was gradually increasing. There was no pain associated with the swelling and the patient denied changes in bowel habit, urine colour, weight loss, appetite change or jaundice.
The dyspnoea occurred only on mobilising or lying flat and there was no report of palpitations, chest pain, cough, sputum, wheeze or haemoptysis. There was no complaint of leg swelling or paroxysmal nocturnal dyspnoea.
She had a 3 year history of rheumatoid arthritis for which she took methotrexate 12.5mg per week, Bucillamine (similar to Penicillamine), folic acid once per week and COX-2 inhibitor when required. Her RA was currently under good control.
She had been informed that she had elevated liver enzymes over 10 years ago and they were observed without intensive investigation. No cause was identified. There was no history of Hep B or Hep C virus infection, no blood transfusions, no IV drug misuse and no tattoos in the past.
She had never drank alcohol and was a non-smoker. There was no family history of note especially no inherited causes of disease. She otherwise lived independently alone and had a good support network of friends. She was unmarried and had never had children. No sexual history was taken. No gynaecological history was taken.
She patient looked well. Afebrile. No Dupytren's contracture, no hepatic flap, no palmar erythema and no spider naevae. No jaundice, no anaemia, no cyanosis, no clubbing, no lymphadenopathy. GCS 15/15.
CVS: Pulse 90/min regular, BP 110/80 mmHg, JVP slight elevation, Heart Sounds normal. No S3 or S4 and no murmurs.
RESP: RR = 30/min, sats 98% on ambient room air, trachea central and no tug, percussion stony dull at both lung bases with decreased tactile vocal fremitus. Lung sounds normal with no crackles but reduced air entry at both bases.
ABDO: Soft, grossly distended abdomen. Non-tender, no obvious masses, no hepatosplenomegally. No rebound or guarding. Bowel sounds normal. Shifting dullness with approximately moderate ascites. Evidence of a previous puncture site on the left lateral abdominal wall. No rectal exam performed.
Pelvis: No gynaecological exam performed.
Extremeties: Pitting oedema of both lower limbs and arms. IV line in left arm with containing 77 mmol Na in 500ml with daily rate at 80ml/hour.
Hands: Swollen. Finger joints normal - no pain, stiffness or restriction of motion. Normal metocarpophalangeal joints, normal wrist joints. No evidence of RA nodules at the elbows.
1) Please make a problem list from the above history and physical examination.
2) Please list several differential diagnosis and please identify one of the likely contributory causes from the history.
3) What tests would you do to confirm your hypothesis?
4) What would be your evidence based treatment strategy for such a patient?
As always, please feel free to send in your attempts at answering the case. The actual case answers will be available in approximately a week. Enjoy sleuthing :-)