An 8-Month History of Vague Systemic Symptoms

Juan Carlos Munoz, MD; Nina Y. Singh, MD; Suraj A. Naik, MD

Disclosures

October 01, 2018

Physical Examination and Workup

Upon examination, the patient appears to be uncomfortable and has a headache and abdominal pain. His oral temperature is 96.6°F (37°C). His pulse is regular at a rate of 126 beats/min. His blood pressure is 120/82 mm Hg. His respiratory rate is 16 breaths/min.

During the initial physical examination, no skin rashes, cyanosis, pallor, or jaundice are noted. The examination of the head and neck is unremarkable. His lungs are clear to auscultation. His cardiac evaluation demonstrates rapid S1 and S2 heart sounds without any murmurs.

His abdomen is protuberant, with mild-to-moderate tenderness over the epigastrium and right upper quadrant along with mild voluntary guarding (but no rebound guarding). He has palpable hepatomegaly but no splenomegaly. No clinical evidence suggests ascites. No surgical scars are noted. Bowel sounds are present. Examination of his extremities reveals normal findings.

The initial laboratory analysis reveals a sodium level of 137 mEq/L, potassium level of 4.6 mEq/L, blood urea nitrogen level of 14 mg/dL, creatinine level of 0.72, white blood cell count of 17.4 × 103/µL, platelet count of 140 × 103/µL, hemoglobin level of 10.2 g/dL, and hematocrit level 31.6%. The liver function tests show an albumin level of 2.6 g/dL, total bilirubin level of 0.5 mg/dL, alkaline phosphatase level of 449 U/L, aspartate aminotransferase level of 49 U/L, and an alanine aminotransferase level of 13 U/L.

An initial chest x-ray shows minimal right basilar subsegmental atelectasis; otherwise, no signs of acute cardiopulmonary disease are noted. Initial CT scanning of the head without contrast is normal. MRI of the brain with and without contrast is unremarkable. CT scanning of the abdomen shows many low-attenuating lesions in the liver. These are of varied size with ill-defined borders, some with water density and some with proteinaceous density. Some of these lesions demonstrate mild enhancement. Enlarged lymph nodes are seen in the left gastric region, the peripancreatic region, at the level of the celiac axis, and in the porta hepatis (Figures 1 and 2.) A gastroenterologist is consulted and recommends an EGD (Figure 3) and an MRI of the liver for further characterization of the liver lesions.

Figure 1.

Figure 2.

Figure 3.

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