Challenge your diagnostic skills

Question 1 of 3 – Select the correct answer

• Presentation: An 83-year-old woman presented to the emergency department with a 4-day history of abdominal pain and mild abdominal distention. The patient reported loss of appetite for the previous two months, involuntary weight loss, nausea without vomiting, and a 1-year history of progressive exertional dyspnea. She also reported progressive, painless bilateral lower limb swelling for the past 3 weeks. She noted she had multiple painless lumps that had appeared three years earlier and had not changed in size.
• History: The patient had hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and heart failure with a preserved ejection fraction of 60.6%. She did not have a history of gastrointestinal disease. The patient reported that she had quit smoking 15 years earlier. She denied any use of alcohol or drugs. Family history was negative for malignancy.
• Physical examination: Vital signs were within normal ranges and the patient was afebrile. Enlarged submental, axillary, and inguinal lymph nodes were detected on examination; nodes were hard, painless, and did not feel warm. Abdominal examination revealed non-tender distention, non-tender hepatosplenomegaly, and a non-tender umbilical mass. Auscultation revealed normal respiratory sounds. The patient exhibited pitting bilateral lower limb edema without tenderness or erythema.
• Laboratory tests:
  • Complete blood count (CBC) with differential: leukocytes (221 × 109/L), lymphocytes (53.56 × 109/L), monocytes (161.61 × 109/L), neutrophils (6 × 109/L), basophils (0.18 × 109/L), eosinophils (0.08 × 109/L), hemoglobin (8.2 g/dL), platelet count (79 × 109/L)
  • Liver function test results: within normal ranges
  • Lactate dehydrogenase: elevated (1,581 U/L)
  • Uric acid: elevated (949 μmol/L)
  • Serum electrolytes: within normal ranges
  • Kidney function test results: within normal ranges
  • HIV, hepatitis B, hepatitis C virus infections: negative

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