This document summarizes a clinical case presentation of a 57-year-old man admitted to the hospital with multiple complaints including neck and groin swelling, abdominal distension, leg swelling, weight loss and black stool. On examination, he was found to have generalized lymphadenopathy, ascites, and reduced breath sounds on the left side. Initial tests showed anemia, renal dysfunction and urine abnormalities. A provisional diagnosis of lymphoma was made, with differential diagnoses of disseminated TB, stomach cancer or CLL. A lymph node biopsy was suggested to confirm the diagnosis. The patient was started on treatment including diuretics and antacids.

1. • ‘He who studies Medicine without books sails an uncharted sea, but
he who studies Medicine without patients does not go to sea at all’
• - Sir William Osler

2. Clinical Meeting
• Presented by
• Dr. Md Limon Mia
• Intern
• Jananeta Nurul Haq Adhunik Hospital

3. Particulars of the Patient
• Name: Mr. Mofiz Ullah
• Age: 57 years
• Sex: Male
• Religion: Islam
• Occupation: Ex CNG Driver
• Address: Devisenpur, Senbagh, Noakhali
• Date of Admission: 02/04/2019
• Date of Examination: 10/04/2019

4. Chief Complaints
• 1. Multiple small swellings in the neck, axillae and groin- 2 months
• 2. Gradual abdominal distension followed by swelling of both legs for
last 20 days
• 3. H/O loss of appetite and weight- 2 months
• 4. Passage of blackish stool for last 20 days

5. History of Present Illness
• As per statement of the patient, he was reasonably well 2 months
back when he noticed painless lumps initially on the right side of the
neck and then on the axillae and both groins. There is occasional rise
of temperature and night sweats in between last 2 months. For last
20 days, his abdomen started to distend followed by swelling of both
legs. He has anorexia and weight loss for the same duration. He
doesn’t have any history of evening rise of temperature, contact with
TB patient and any abnormal bleeding. He also complaints of
constipation with passage of black tarry stool for last 20 days as well
as oliguria. He is hypertensive and non diabetic.

6. History of Past Illness
• Nothing significant

7. Personal History
• Non smoker and non alcoholic, Occasionally takes betel leaf and nut.

8. Family History
• Nothing significant

9. Socio-economic History
• He is from a lower class background.

10. Drug History
• He used to take pain killers in last 2 years at variable intervals.

11. General Examination
• Appearance: cachectic and ill looking
• Body Built: below average
• Co-operation: Co-operative
• Anemia: ++
• Jaundice: Absent
• Cyanosis: Absent
• Koilonychia: Absent
• Leuconychia: Absent
• Edema: Bilateral pedal pitting edema
• Dehydration: +
• Thyroid: Normal
• Bony Tenderness: Absent

12. Continuing General Examination
• Lymph Nodes:
• - Right cervical
• - Both axillary
• - Right epitrochlear
• - Both inguinals
• All the above mentioned lymph nodes are enlarged and variable at
size and shape, the largest one measuring about 2X2 cm. They are
non tender, rubbery in consistency, discreet. Not adherent to
underlying structure or overlying skin. There is no discharging sinus.

13. Continuing General Examination
• Pulse: 84 bpm
• BP: 140/90 mmHg
• RR: 30 bpm
• Temperature: 99 degree F
• Bed side heat coagulation test: +

14. Systemic Examination
• A) Alimentary System
• B) Respiratory System
• C) Others

15. Alimentary System
• Inspection
• The abdomen is distended, umbilicus centrally placed and inverted. There are ulcers on either
sides of umbilicus showing features of quackery. No engorged vein, visible mass or peristalsis.
• Palpation
• The liver is palpable- about 7 cm from the right costal margin along the mid clavicular line. Upper
border of liver dullness is at right 5th intercostal space, margin is sharp, surface smooth, non
tender and firm in consistency. No hepatic bruit or rub. Spleen is not enlarged and kidneys are not
ballotable.
• Percussion
• Shifting Dullness: Present
• Fluid Thrill: Absent
• Auscultation
• No abnormality detected

16. Respiratory System
• Inspection
• Chest movement restricted on left side
• Palpation
• Trachea- slightly shifted to the right
• Chest expansibility- restricted on the left
• Apex beat- at left 4th intercostal space, 7 cm from the midline
• Vocal fremitus- reduced on left
• Percussion
• Stony dull over the left chest
• Auscultation
• Breath sound diminished on the left side
• Vocal resonance reduced on the left
• No added sound

17. Other Systems
• Reveal no abnormality

18. Salient feature
• Mr. Mofiz Ullah, 57, hypertensive, non diabetic, hailing from Senbagh,
Noakhali, admitted into this hospital with complaints of painless lump
initially on the right side of the neck and then on the axillae and both
groins. There is occasional rise of temperature and night sweats in between
last 2 months. For last 20 days, his abdomen started to distend followed by
swelling of both legs. He has anorexia and weight loss for the same
duration. He doesn’t have any history of evening rise of temperature,
contact with TB patient and any abnormal bleeding. He also complaints of
constipation with passage of black tarry stool for last 20 days as well as
oliguria.
• He is cachectic, moderately anaemic. There is generalized
lymphadenopathy. Pulse is 84 bpm, BP 140/90 mmHg, RR 30 bpm and
temperature 99 degree F.

19. Continuing Salient Feature…..
• The abdomen is distended, umbilicus centrally placed and inverted.
The liver palpable- about 7 cm from the right costal margin along the
mid clavicular line. Shifting dullness is present.
• Chest movement is restricted on left side, trachea and apex beat are
slightly shifted to the right and stony dull on percussion over the left
chest. Breath sound diminished on same side.

20. Provisional Diagnosis
• Lymphoma

21. Differential Diagnosis
• 1. Dessiminated TB
• 2. Ca Stomach
• 3. CLL

22. Investigations
• Hb%: 10.28 gm/dL
• ESR: 115 mm at 1st hour
• WBC: 12,000/cmm
• Neutrophil: 80%
• Lymphocyte: 18%
• Monocyte: 1%

23. Continuing Investigation…..
• S. bilirubin: 0.68 mg/dL
• SGPT: 19 IU/L
• HBs Ag: Negative
• Anti HCV antibody: Negative
• Anti HBc total: Negative

24. Continuing Investigation…..
• Urine R/E:
• Appearance: Hazy
• Albumin: +++
• Pus cell: 15-20/HPF
• Epithelial cell: 4-6/HPF
• RBC: 2-4/HPF

25. Continuing Investigation…..
• RBS: 6.64 mmol/L
• S. creatinine: 2.59 mg/dL
• eGFR: 19.14 ml/min/1.73m2
• S. electrolytes
• Na+ 128 mmol/L
• K+ 3.32 mmol/L
• Cl- 96.42 mmol/L

26. Continuing Investigation…..
• USG of W/A
• - Left sided pleural effusion
• - Mild hydronephrosis left
• - Mild hepatomegaly (16.2 cm)
• - Cortical echogenicity is increased in both kidneys- suggestive of
bilateral renal parenchymal disease
• - Moderate ascites is noted

27. Continuing Investigation…..

28. Continuing Investigation…..

29. Most Probable Diagnosis
• Lymphoma with PUD with CKD (stage IV)

30. Investigation I would like to suggest
• Lymph node biopsy

31. Ongoing Treatment
• Diet: Salt and fluid restriction
• Tab. Sefur 250mg 1+0+1
• Tab. Lasix 40mg 1+1+0
• Tab. Lok 50mg 1+0+0
• Tab. Dicaltrol Plus 0+1+0
• Tab. Omidon 10mg 1+1+1
• Tab. Rabe 20mg 1+0+1
• Syp. Avolac 3 TSF X TDS
• Ointment Bactrocin 2%

32. •
• Thanks all!