CPC #3: Tuesday, November 26, 2002
Hurd Hall, The Johns Hopkins Hospital
12:00 Noon

Chief Complaint:
A 52-year-old female with left-sided abdominal pain and diarrhea.

History of Present Illness:
A 52-year-old woman developed left-sided abdominal pain and severe diarrhea during March of 1999. Her abdominal pain was cramping and mildly relieved by food, but not with defecation. Her diarrhea was watery, she had >4 bowel movements each day. There was no hematemesis or melena. Her symptoms persisted with varying severity and no relief with over-the –counter medications. In August of 1999, she underwent an upper endoscopy that revealed multiple ulcers in the stomach and duodenum. A biopsy for Helicobacter pylori was negative. She was started on Omeprazole with resolution of her abdominal pain and diarrhea.

When the proton pump inhibitor was discontinued several months later, her diarrhea and abdominal discomfort returned. During August of 2000, an upper GI series again demonstrated a duodenal ulcer. A serum gastrin level was normal. Her stool was negative for WBCs, ova, parasites, or C. difficile. An abdominal MRI was reportedly negative. She was restarted on Omeprazole and followed.

During 2002, an abdominal MRI reportedly demonstrated a solitary lesion in the medial segment of the left lobe of the liver. No other upper GI abnormalities were noted by imaging studies. In April of 2002, the patient underwent an unremarkable upper endoscopy at The Johns Hopkins Hospital. No ulcers were seen.

Review of Systems:
Notable for paresthesias of the left hand, anxiety, and intermittent vaginal spotting.

Past Medical History:
Borderline hypertension and three normal spontaneous vaginal deliveries.

Past Surgical History:
She is status post tonsillectomy and adenoidectomy as a child.

Social History:
She is married with three grown children, and works as a homemaker. She denies alcohol or tobacco use. She has not traveled overseas in over 5 years. She lives in a suburban setting and has no contact with farm animals or products. She eats a normal diet.

Family History:
Her father had cardiac disease and hypertension, and died of a myocardial infarction. Her mother is alive with thyroid disease. Her three siblings are healthy. There is no family history of cancer or diabetes mellitus.

Allergies:
No known drug allergies. No known allergies to latex.

Physical Examination:
The patient is a well-developed, well-nourished white female in no acute distress. Vital signs reveal blood pressure 144/83, pulse 85, respiratory rate 18, O2 sat 99% on room air, and temperature 35.7?C. Head and neck exam reveals no thyromegaly or lymphadenopathy. Lungs are clear to auscultation bilaterally. Cardiac exam is unremarkable with no murmurs, gallops, or rubs appreciated. Abdomen is soft, nontender, and nondistended. Rectal examination was normal, with hemoccult negative stool. There is no hepatosplenomegaly or periumbilical adenopathy. Neurological exam is unremarkable.

Laboratory Studies:
CBC: WBC 6100/mm3 , HgB 13.6 g/dL, Hct 39.5%, MCV 90.4fL, RDW 13.4%, platelets
268,000/mm3
Basic metabolic panel showed the following results: Sodium 140 mEq/L, potassium 3.8
mEq/L, chloride 101 mEq/L, BUN 10 mg/dL, creatinine 0.7 mg/dL, glucose 95 mg/dL, bicarbonate 26 mEq/L
Liver function tests demonstrated the following: Total protein 7.8 g/dL, albumin 4.5
g/dL, total bilirubin 0.5 mg/dL, ALT 11 IU/L, AST 17 IU/L, alkaline phosphatase 73
IU/L
Amylase 54 IU/L, Lipase 27 IU/dL
Ca²⁺ 10.1 mg/dL
CA 19-9 = 40.4 U/mL (1-36)

Radiological studies at JHH:
CT scan (Figures 1,2,3)

Figure 1
Coronal reformatted CT image of the stomach.

Figure 2.
Axial CT image of the liver, acquired during the early arterial phase of contrast injection, shows a 1.2 cm enhancing mass (arrow) in the left lobe of the liver. Note, the intense enhancement of the aorta and poor visualization of the portal vein, which is characteristic for the arterial phase.

Figure 3
3D reformatted image of the abdominal aorta shows a hepatic artery branch (black arrow) supplying the mass in the left lobe of the liver (white arrow).

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