A 70 year old female with constipation, Anemia, post prandial pain abdomen

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I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.

 

This is a case of a 70 year old female admitted in the ward, with a history of 

low grade fever

loss of appetite

constipation. 

History of presenting illness

She presented with a 15 day history of early satiety and post prandial pain. i.e, she eats at 1:00 pm; develops pain at around 3-4 pm in afternoon in left hypochondrium region burning type non radiating, which is gradually progressive and severe by around 3-4pm , vomits (induced) at around 6 pm). The vomiting is non bilious non blood stained non foul smelling food as content.

She also complains of occasional occurence of streaks of blood in stools which probably is more likely to be because of anal fissure due to constipation

She was diagnosed as having a duodenal ulcer. And due to severe Anemia she was given blood transfusion.

In the year 2020, history of Endometrial carcinoma for which she was treated with Chemotherapy and radiotherapy in MNJ for 1 and a half month.

3 years ago, she fell from an auto, while sitting at the back in a 7 seater and slipped and fell when the auto sped over a speedbreaker. She had a femur fracture which was operated on (proximal femoral nail). She denies having lost consciousness at that time. No h/o trauma to head and other injuries.

She also reports dizziness and transient blackouts while she brushes her teeth after she gets up from the bed.

Past history- 

She was diagnosed with hypertension 10 years ago and is on regular medications.

No h/o DM Bronchial asthma CAD TB COPD

No h/o past surgeries (except for femur nail implant)

Personal history-

Diet- mixed

Appetite- decreased

Sleep- adequate

Bowel (constipated) and bladder regular

No Addictions

Family history

Not significant

Allergic history

No known allergies 

General physical examination-

Vitals - PR - 76 BPM

BP - 170/80 mm Hg

RR - 16/min

Temp - 100.6°F

Temporal wasting, deltoid wasting, increased skinfold thickness at triceps, mild proximal myopathy

Pallor ++

No icterus cyanosis clubbing lymphadenopathy pedal edema

Pale tongue  

Hyperpigmented lesions on tongue

Maculopapular lesions on lower chest and upper abdomen 

Pedal edema 

Pitting type grade 2

(edema resolving over several minutes)

CVS - 

Inspection-

Shape of chest- elliptical

No scars dilated veins

No raised JVP

Apical impulse visible and appeared to be heaving.

Palpation-

Apex beat felt in left 6th ICS MCL more laterally

Parasternal heave+

Collapsing water hammer pulse + (felt in carotids)

No radio radial delay. 

No thrills,

Auscultation- 

An ejection systolic murmur in the aortic area without Gallavardin phenomenon. S3 heard in mitral area. 

GIT examination- 

Inspection

Shape of abdomen- scaphoid

No scars sinuses visible pulsations dilated veins abdominal distension

All quadrants moving with respiration

Umbilicus everted

On palpation

No tenderness

No local rise of temperature

Soft abdomen, no organomegaly 

Percussion

Liver dullness in 5th ICS 

Splenic dull note in 8th ICS MAL (mild splenomegaly)

Auscultation

Bowel sounds heard

CNS - 

Higher mental functions- intact

Cranial nerves intact 

Sensory- fine touch, crude touch, pressure, temperature, vibration senses intact.

Motor system

Power: 5/5 in both UL and LL

Tone- normal 

Bulk - decreased

Reflexes:

Biceps, Triceps Supinator Knee reflexes intact (++) 

No cerebellar signs noticed

Respiratory system - 

 Shape of chest elliptical

B/l symmetrical expansion of chest wall+

Position of trachea- central

Resonance present in all lung fields

BAE+ NVBS+

No crepitations heard

Hemogram- Severe anemia ; Hb 4.3

Iron studies- serum ferritin at 3.9 ng/ml - iron deficiency

Hypoalbuminemia at 3.2g/dl. Creatinine at 1.5mg/dl with eGFR at 40 ml/min/1.73m2

CXR - 

Showing left ventricular hypertrophy with unfolding of aorta

ECG

USG abdomen-

Revealed- mild ascites

Right renal cal

Renal cortical cysts

2D Echo - 

Moderate to Severe AR

Moderate to Severe AS 

AS (thickened calcific) + AR + Concentric LVH (IVS at 1.5cm, and HTN since only 4 years which is usually well controlled) 

Diagnosis -

Metastatic carcinoma?

Amyloidosis?

Pernicious Anemia