Case report III

Patient with fatigue and swelling of legs and abdomen


Marie Novakova (55 years) works as an accountant for her whole life. She was admitted to an internal department for anorexia, intermittent diffuse abdominal pain and pressure independent of meals, flatulence and increase abdominal circumference. At the same time she complains about symmetric swelling of legs to the knees and about fatigue.

The doctor took following history:

History of presenting complaint:

She celebrated her birthday six days ago. Since that, she feels tired, has no appetite, her legs began to swell and her abdomen is bigger. She feels intermittent diffuse abdominal pain and pressure independent of meals. She gained 4kg during these six days. She noticed that her urine is darker and her eyes are yellow.

Past medical history:

Common childhood diseases, in 25 years – car accident with serious pelvic trauma, several week on resuscitation unit, reoperations, 2 years of rehabilitation. Other serious illness not mentioned.


1972 appendectomy

1982 operation of pelvic trauma after a car accident (several reoperations), large blood loss –  blood transfusion

Abuse: 10 cigarettes a day. Alcohol: 1,5dcl of wine per day, spirits only occasionally

Family history: father died in 72 years – heart disease, mother died in 75 years – breast cancer, brother and sister are healthy, 2 healthy children

Gynaecological history: menarche in 13 years, 2 spontaneous births, miscarriages 0, menopause in 52 years

Pharmacological history: 0 (only occasionally Ibuprofen 400 for headache)

Allergy history: 0


How would you assess the amount of alcohol that Mrs. Novakova regularly drinks?

How does our body metabolize ethanol? Does the metabolism differ in occasional users and in alcoholics?

The doctor performed physical examination (only pathological findings):

Physical examination: blood pressure 110/60, heart rate 95/min regular, respiratory rate 12/min, temperature 36,2 °C

Patient oriented, skin a sclerae icteric, muscle atrophy. Findings typical for liver disease – distended abdomen, in right hypochondrium enlarged liver (+3 cm). Lower extremities with symmetric swelling to the knees.

Basic laboratory investigation:

WBC 5,6×109/l; RBC 4,5×1012/l; Platelets 160×109/l; Hemoglobin 129 g/l; Hematocrit 46%

Glycemia 3,1 mmol/l; Na 140 mmol/l; K 3,9 mmol/l; ALT 5,1 μkat/l; AST 4,7 μkat/l; ALP 2,0 μkat/l; GMT 4,2 μkat/l; total bilirubin 50 μmol/l; albumin 25 g/l; cholesterol 2,5 mmol/l


INR 2,3


proteins 0; blood 0; bilirubin +++; urobilinogen +++


Can any laboratory result clarify swelling in this patient?

Do lab results show an impairment of some organ(s)?

Could you determine what type of icterus has Mrs. Novakova?

To gain more information about possible causes of this state, took the doctor blood and sent it to a serology investigation and electrophoresis of blood proteins. Here are results:

HBs antigen – negative

anti-HCV – negative

In blood protein electrophoresis: relatively increased fraction of gamaglobulins and relatively decreased levels of albumin and alpha-l and alpha-2 globulins.


What is a meaning of results of HBs antigen and anti-HCV?

Draw a physiological result of blood protein electrophoresis and mark there changes mentioned above. Are these changes typical for some organ impairment?

Mrs. Novakova was sent to a specialized department to ensure adequate therapy.


In treatment of disease, that Mrs. Novakova suffers, plays a very significant role proper nutrition. What is necessary to change in her diet?