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CPC Case for January 6, 2005

Presenter:  Kate Moran, MD
Discussant: William Stevens, MD
Pathologist: Beverly Dickson, MD

CC

Abdominal pain
HPI

A 32 year old Latin-American male with no significant past medical history presented to the emergency room with a one week history of right upper quadrant and epigastric abdominal pain.  Two weeks ago he started having fevers as high as 103 degrees associated with chills and night sweats.  One week ago he developed abdominal pain was initially mild and cramping but gradually worsened to severe, sharp pain.  The pain was better while sitting upright or moving and worsened by lying down or staying still.  He denied any radiation of the pain. 
PMH

Childhood asthma

MEDICATIONS

None
FH Mother died at age 74 from cancer of unknown type.  He has four siblings with diabetes mellitus.  Denies any family history of cancer.

SH

 He is a single, sexually active homosexual male.  He reported being HIV negative one year ago.  He has had multiple sexual partners, and admited to having unprotected sex in the past year.  He smoked 1⁄2 pack per day for 14 years but quit 2 weeks ago.  He had three tattoos placed three years ago.  He denied alcohol or illicit drug use, blood transfusions, or recent travel.
ALLERGIES N/A
ROS

ROS:  He also reported a 5-10 lb weight loss over the past 2-3 months.  He denied cough, chest pain, vomiting, diarrhea, dysuria, rash, or arthralgias.
PHYSICAL EXAM:

Vitals:   Tmax 102.2   Tcurrent 98.5°    P105    R14   BP113/90    SaO2 98%      Wt 68kg

Gen:  Well developed male lying in bed in mild distress due to abdominal  pain

HEENT:  Anicteric sclerae, mucous membranes pale and moist.  Oropharynx without ulcers or thrush.
Neck:   Supple, carotids 2+ bilaterally.  No JVD, thyromegaly, or   lymphadenopathy.
Lungs:  Clear to auscultation bilaterally.
Cardiac:  Regular rate and rhythm.  Normal S1 and S2.  No murmurs, rubs, or gallops.
Abdomen:  Soft, tender to palpation in right upper quadrant, no rebound tenderness or involuntary guarding, negative Murphy’s sign.  Liver edge is smooth and palpable 2 cm below costal margin. No splenomegaly or distention. Normal active bowel sounds.  Guaiac negative.
Extremities:  No lower extremity edema.  2+ distal pulses.
Skin:  No rash
LABS:
Na
142
K
 4.4
Cl
 103
HCO3
 29
Glucose
 95
BUN
 15
Ca
8.4
Mg
 2.3
Phos
4.1
        
Creatinine
 1.0
Alk Phos
 215
AST
90
ALT
72
TP
8.3
Alb
 3.8
Total Bili
0.3
Lipase
 108
GGT
 109
ESR
 68
CRP
 8.7
Glob
 4.5
 
   
 
 
 
 
 
PT
 14.6
PTT
 40.9
INR
 1.1
 
 
 
   
 
 
 
 
 
WBC
 5,470
Hgb
 11.9
Hct
 37.1
Plts
 305,000
MCV
 85
 
Imaging and Other Studies
CT abdomen/pelvis

8.5cm complex, cystic, heterogeneous mass centered in Morrison’s pouch with involvement of liver.

Compression of IVC with thrombus inferiorly extending to bilateral common femoral veins.

No intrahepatic biliary ductal dilatation. 

Small amount of ascites.
Hospital Course A diagnostic procedure was performed.