Given these changes from the original case, what is your diagnosis?
What is your diagnostic explanation?
As compared to the long case, this patient is a 35 year old female who presents to the clinic with the chief complaint of “My legs are swelling and I have been gaining weight.” She reports edema bilaterally in the legs that is worse at the end of the day. She denies any leg warmth, redness, or any recent immobilization. She also reports gaining 15 pounds over the past 2 months. She believes that all of her weight was gained in her abdomen. She reports that her clothes no longer fit because her abdomen has increased in size. She reports fatigue that has progressively worsened and she feels like sleeping all the time. She reports sleeping 8 – 9 hours per night despite taking at least one afternoon nap. She also has noticed her skin feels drier than usual.
Tobacco: 30 pack year history (2 ppd x 15 years)
Alcohol: Drinks at least 8 beers per day; reports drinking up to 20 beers per day on the weekends; also drinks 1 pint of vodka every week
Caffeine: 2 – 3 cups of coffee per day
Appearance: Mildly obese patient who appears older than her stated age, in no distress.
VS: BP 130/80, P 65, RR 18, BMI 30, T 99F.
HEENT: Conjunctiva mildly jaundiced. Swelling present around the eyes.
Cardiovascular: Bradycardia. Regular rhythm. S1 and S2 of normal intensity. No murmurs, rubs, or gallops. 2+ edema present bilaterally in the lower extremities.
Abdominal: Distended. Fluid wave present. Non-tender to palpation in any quadrant. Bowel sounds present in all quadrants.
Skin: Warm and dry. Slight jaundice noted. Several spider angiomas present over extremities. Palmar erythema present.
Musculoskeletal: Full ROM of extremities. Hand flapping tremor present. No weakness noted in upper or lower extremities.
CBC: macrocytic anemia, MCV 100
Blood smear: target cells present
Folate and B12 levels: decreased
CMP: AST 210; ALT 80; Ammonia 50 mcg/dL
Abdominal CT/US: ascites noted