Elle Bow
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Elle Bow is a 75 year old woman who has been admitted with abdominal swelling. She has ongoing pathology in her abdomen for which she is receiving treatment. Her medication list includes:
Regular - Lanzoprazole
Acute - Furosemide - Magnesium Glycerophosphate
Recently discontinued - Cisplatin - Dexamethasone - Gemcitabine
Please take a history focusing on the acute problem which has brought her into hospital on this occasion. Elle has had a number of problems going on, so please focus on her abdominal pathology and perform the appropriate examination. You will then be asked to discuss the case with the examiner.
You are Elle Bow, a 75 year old lady with an interest in card games. You’re your country’s reigning bridge champion! However, things have been going downhill in your life over the past year or so, particularly with your health
6 months ago you were diagnosed with a cancer of your bile duct. You initially noticed that you were losing weight, and one of your friends at bingo night told you that they noticed that your eyes were yellow. You were astonished at this: your cousin once had this, but he drank a lot of alcohol, so you thought it was down to that. You don’t even drink! You went straight to the doctor and they did some tests. In the end, you got your diagnosis, and were started on chemotherapy. You had your last cycle just last month, and are hoping that this will improve things.
HPC: For this hospital admission, you have come in for three reasons. Firstly, your feet are really swollen. They’ve blown up like balloons! You felt like you were a hippo when walking, and it was stopping you getting around. They both have swollen up equally, and it happened relatively quickly, over the past fortnight. They are not read, and are just a bit painful as the skin feels tight. Staying at your legs, your feet have become very tingly, as well as your hands. You’re getting lots of pins and needles, and noticing that it’s quite hard to feel anything touching them from time to time. This has puzzled you and is very frustrating as it’s stopping you playing online card games. Finally your tummy has swollen again. This happened last month, but it’s much worse this time. It feels like you’re pregnant! This has affected your breathing: you now find it quite difficult to lie flat. It’s generally a bit sore, but not over any particular area. You haven’t noticed any difficulty swallowing, any bleeding from anywhere, or any vomiting. You think you would notice those things if they happened: you’re still quite sharp! Your bowel habit is fine and you haven’t had any problems going to the toilet.
PMH: You were diagnosed with a bile duct tumour this year and have been on a few cycles of chemotherapy for this. You had previously been very well and hadn’t really been in hospital for many things. You had your gall bladder taken out a few years ago and have had to go for checks on this.
ICE: You think that this is the fluid building up in your tummy again. They haven’t put any drains in this time, and are wondering whether they will just bite the bullet and do it quickly this time instead of messing around. You don’t want to be beaten by the cancer: you’re very knowledgable about what is going on - reading up on everything! You’re not sure what is causing the tingling in your hands. Could it be the chemotherapy?
Social history: You live at home alone. You have had a few partners but never married - you’re fiercely independent and want to keep things that way! You have a cat called Toulouse which just gets on and does its own thing. It seems that it’s your spirit animal! You have never drank alcohol to excess - maybe a glass of wine at Christmas - and you don’t smoke. Before these last few weeks, you had been managing at home just fine.
Drug history: You are allergic to penicillin - you had a very bad reaction when you were a child but don’t really remember it.
The student should undertake a focused history on the presenting problem. This patient has a number of presenting complaints and a comprehensive past medical history, so it may prove difficult to pin down the most pertinent points, but the excellent candidate will focus in on the abdominal swelling, as is suggested in the question. Candidates may also identify the leg swelling (important to the patient) and the tingling in the hands (peripheral neuropathy) as key features to explore. An abdominal exam would be appropriate. This patient would have ascites and a Sister Mary Joseph nodule.
An example differential diagnosis may sound something like:
‘My primary differential diagnosis would be a gastrointestinal problem, more specifically ascites secondary to malignancy. This is because of the history of cholangiocarcinoma and the acute abdominal distention. The patient is also experiencing distal limb paraesthesia and numbness - potentially due to peripheral neuropathy secondary to cisplatin chemotherapy. I would also want to rule out metastases potentially causing neurology - including paraneoplastic syndrome or any bowel malignancy.’
Possibly questions for discussion may include:
- How are ascites classified?
- How are ascites managed?
- How may cholangiocarcinoma present?
- How is cholangiocarcinoma diagnosed?
