BRIANNA LANG

Write-Up Low Resource Clinical Reasoning Case

This write up will be posted in your Virtual Elective E-Portfolio.

Instructions: Choose one case which was discussed this week.

Section 1: Copy-paste the history and exam of the case you choose.

Then, create a 1-2 page write up that includes the following:

Section 2: the "frame" of the case: the 4-5 (bulleted) key clinical features from the history that
the final diagnosis must be consistent with. Next to each item of the frame you create, explain
why that item is important and/or how it will help orient/organize your differential diagnosis.

Section 3: Select 3-5 features of the physical exam, and for each, explain its clinical significance

Section 4: List at least 3 etiologies/disease that are on the differential diagnosis for the patient's
presentation.

Section 5: Discuss the true diagnosis(es) of the patient and why it is more likely than the other
options on your differential.

Case 6

A 26 year old man presents with weight loss and increasing epigastric and right-sided belly
pain. He was previously an accountant in Chad who’s been running a small news stand on the
Southside for 4 years after visiting Chicago (in the US) for his cousin’s wedding and overstaying
his visa. He was in his usual fully functional state of health until he started losing his appetite
and feeling progressive fatigue about 6 months ago. He first noticed weight loss 4 months ago
and pain in the center and right side of his abdomen 2 months ago. The pain started as a dull
continuous ache that grew more intense, and although unrelated to meals, lately has been
associated with an early fullness and discomfort when eating. He’s felt “hot” on and off. He’s
had no prior history of significant abdominal pain, liver disease, diarrhea, change in bowel
habits, or change in color of his stool, skin or urine. He’s been a social drinker only, married
and always monogamous with his wife of 8 years who’s living with him. He has 2 kids in Chad
who stay with his parents and whom he sends money to. He delayed coming to the clinic for
fear of deportation.

Physical Exam: cachectic, and in no acute distress.

BP 90/60, HR 100 and T 100.2 orally.

Conjunctiva are without pallor or icterus;

Neck normal lymph nodes, JVP and thyroid;

Lungs and heart are normal.

Abdomen is slightly distended, hard, tender, mass in the right upper quadrant which moves
with respiration, extending 16 cm below the costal margin, spanning 23 cm, with an irregular
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nodular edge; a bruit can be heard over the mass. Spleen descends 2 cm below the costal
margin; no shifting dullness.

Stool: guaiac negative.

Extremities: no clubbing or edema.

FRAME 26 year old immigrant male with epigastric pain an bloody sputum

KEY FEATURES

- Loss of appetite and fatigue 6 months ago, weight loss 4 months ago, abdominal pain
for 2 months ago
- Abdominal pain was dull and continuous, grew more intense with the time, associated
with early satiety and eating discomfort ( but not associated with meals) but no
change in stools
- Reports feeling hot on and off
- Cachectic appearing this could have a relationship with de loss of weight for about
four months
- Abdominal is mildy distended,RUQ mobile (with respiration) mass that is 16 cm below
the costal margin/23 cm total, has irregular nodular edge, and has bruit auscultation
- Soft BP, With mild tachycardia and low grave fever

DIFFERENTIAL DIAGNOSIS

- Tuberculosis
- Pneumonia
- Leukemia

TRUE DIAGNOSIS

- HEPATOCARCINOMA
- LYMPHOMA