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Case Number : Test Case Chief Complaint : 39 y/o female with abdominal pain Presented by : Heeman Kwack
History of Present Illness A 39 y/o female presents to Rehoboth Medical Center with right upper quadrant pain times 6 days.  Patient describes the pain as sharp, located in right upper quadrant, constant, denies any radiation of pain.  Patient was seen 3 days PTA with similar pain at Fr. Defiance.  Labs were obtained and the patient was given a diagnosis of acute hepatitis. Pt denies any fever, aches, or chills.  She describes mild nausea with a sense of ‘fullness’ in her abdomen.  She denies vomiting or fever, no SOB or cough, admits to baseline dyspnea on exertion.  Pt denies any history of GERD or previous GI bleeds, no known gallstones, no relation of the pain to eating.  Pt has not notices any skin discoloration or itching. PMH- pt has a history of asthma treated with inhalers, no other significant PMH.  Pt denies hx of IVDA or recent travel, no history of blood transfusion Meds- Inhalers ALL- NKDA Family Hisotry- mom has a history of cardiomyopathy
Physical Exam Vitals T AF BP 100/70 P 115 O2Sat 90s Gen mildly obese female, NAD HEENT NC/AT Eyes- no scleral icterus Oral- no reported lesions, mucosa moist Neck- 6-8 cm JVD, no LAD Lungs- diffuse wheezing with prolonged expirations, no rales CV- RR, tachy, nl S1S2, no m/r/g Abd- mild RUQ tenderness, no guarding, neg Murphy’s, + hepatojugular reflex Ext- no evidence of per edema Skin- warm, dry, no jaundice or lesions
12 lead ECG- NSR with diffuse T-wave inversions, low voltage	Chest X-ray
Differential Diagnosis 1.       Hepatitis 2.        Gallstones 3.        Pancreatitis 4.        Right-sided heart failure secondary to pulmonary condition (cor pulmonale), valvular abn 5.        Cardiomyopathy 6.        PE 7.        Rheumatologic Abnormality
Laboratory Values WBC 11,000 HcT 52 Plts 186 LFTs- AST 77 ALT 93 Alk phos 148 Tbili 1.0 Alb nl Amylase- nl U/A- nl PGU- neg RUQ U/S- nl gallbladder, no ascites, no stones, small pericardial effusion seen
Clinical Course Given the pts enlarged cardiac silhoutte, mild hepatic congestion, tachycardia, and pericardial effusion seen on u/s, she was transferred to the Heart Hospital in Albuquerque for further evaluation. Echocardiogram at Heart Hospital revealed dilated right atrium and ventricle, nl LV-function, moderate size pericardial effusion, and elevated PA pressures.  Pt symptomatically got better but then returned to the Heart Hospital with similar complaints.  Pt underwent Left Heart Catheterization which revealed continued eleveate PA pressures.  A nipride test was performed which was negative.
Final Diagnosis Primary Pulmonary Hypertension Discussion- Primary Pulmonary Hypertension is characteristically a disease of young adult women with a 10-15% familial inherited pattern.  Patients typically present in their 20s to 30s after an exposure to some intrinsic or extrinsic stimulus which then reveals the underlying pathophysiology.  The pathogenesis continues to be speculative with an underlying inflammatory or immunologic injury to the pulmonary endothelium, resulting in an imbalance of locally produced vasoconstrictor (thromboxane, endothelin) and vasodilator (prostacyclin) factors.   Pts typically present with progressive dyspnea and exercise limitation, occasional syncopal episodes, with eventual cor pulmonale (like our patient). Treatment includes chronic anticoagulation (coumadin), prostaglandins, and calcium-channel blockers.
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