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Case Study

A 55-year-old man with weight loss and hepatomegaly

A 55-year-old man seen at your office complains of fatigue, a 20-pound weight loss, and anorexia over the past 2 to 3 months. He has previously been in good health, except for a history of hypertension, for which he has been treated with hydrochlorothiazide, 50 mg a day, for the past 3 years. He takes no other medications, has never had a blood transfusion, and has not travelled outside the United States. He consumes 2 to 3 alcoholic beverages a week and does not smoke tobacco.

Questioning reveals that he has been a car salesman for 25 years. He is married, has 3 children, and has lived near an industrial park for the last 18 years. Three and a half years ago, he and his family were evacuated from their home for several days after a railroad tanker car derailed and ruptured on the nearby railroad tracks. He and his family were treated at a local emergency room for sore throat and cough; acute respiratory complaints resolved within 2 weeks. He does not recall the name of the chemical that was released, but he remembers it had a slightly sweet odor, an odor he has occasionally noticed while in the backyard. His youngest daughter, who has just turned 19, gave birth to a boy last week; the pregnancy was troubled, but the baby is fine. The rest of his family is in good health.

On physical examination, your patient appears to be in poor health. Blood pressure is 140/80; pulse is 72 and regular. He is afebrile. Weight is 174 pounds. There are no skin rashes or lesions. Sclerae are slightly icteric; the remainder of the HEENT examination is normal. There is no thyromegaly or lymphadenopathy. The results of heart and chest examination are normal. The patient’s liver is 14 cm in span, percusses at the midclavicular line, and is slightly tender to palpation; the lower border is palpable 4 cm below the costal margin. The spleen is not enlarged, and there are no other abdominal masses. Extremities and joints are unremarkable, and the results of neurologic examination are completely normal. Prostate is normal-sized; no masses are felt, and the stool is negative for occult blood.

The initial laboratory results include hemoglobin, white blood cell count, electrolytes, and urinalysis, all normal. The SGPT is 372 IU/L and SGOT is 293 IU/L. Bilirubin, alkaline phosphatase, and serum protein levels are within normal limits.

(a) What should be included in this patient’s problem list?


(b) What is the differential diagnosis for this patient?


(c) What tests would you order to confirm or rule out these diagnoses?


Answers are incorporated in Challenge answers (6) through (9) on pages 17–18.

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