Internal Medicine Quiz-Case 9 Figure 1

Archives Of, Medicine
2008 unpublished
a 60-year-old woman was admitted for progressive pitting edema of the lower part of the body and dyspnea on exertion, which started 3 months ago. Sixteen months ago, she had received chemotherapy and radiation therapy for cancer of the uterine cervix that was locally advanced, encroaching the left ureter. She was a former smoker with 5 pack years. Her medical history was unremarkable. on physical examination her vitals were BP 120/70 mmHg, HR 100/min, RR 26/min and her temperature was normal.
more » ... ature was normal. Symmetrical edema of the lower half of the body up to the umbilicus and the lumbar area was noted. The edema was pitting, soft and non-tender, and worsened on assumption of upright posture. No lymph nodes were palpable. auscultation of the heart was normal and the jugular veins were not distended. lung auscultation revealed reduced breath sounds at the right base, accompanied by dullness on percussion. The abdomen was non-tender, distended symmetrically due to ascites, and distention of the veins of the lateral abdominal wall with cephalad blood flow was noted (fig. 1). laboratory testing showed elevated serum urea at 103 mg/dl (range 17-50 mg/dl) and creatinine at 2 mg/dl (range 0.6-1.2 mg/dl), hyponatremia (126 mmol/l, range 136-145 mmol/l), and elevated alanine aminotransferase (349 u/l, range 5-40 u/l), aspartate aminotransferase (141 u/l, range 5-40 u/l), alkaline phosphatase (684 u/l, range 64-280 u/l), γ-GT (396 u/l, range 7-32 u/l), ldH (1,015 u/l, range 200-460 u/l) and CPK (303 u/l, range 20-190 u/l) and a normal serum protein electrophoretic pattern. a chest X-ray was obtained that showed normal lung parenchyma and cardiothoracic index, but a mild elevation of the right hemidiaphragm. on echocardiography of the heart the left ventricular ejection fraction was shown to be normal (>65%), along with the cardiac valves and the pericardium, ruling out cardiac failure. Paracentesis of the ascitic fluid proved it to be portal hypertensive ascites with a SaaG (serum-ascites albumin gradient) of 2, negative cultures and negative cytologic examination. an ultrasound examination of the liver and spleen was ordered, which apart from the ascites revealed no abnormalities, whereas a lower abdomen ultrasound showed a normal right kidney, but