Anmolpreet Gurwal

Hello, everyone.

I am very excited to be here at the SLS.

My name is Anmol Preet.

You can call me Anmol.

And I'm a physician from India aiming for my internal medicine residency.

Very excited to be here.

We have an 84-year-old male with JAK2 positive thrombocytosis and atrial fibrillation on anticoagulation.

He presented to us with acute onset severe intermittent right upper quadrant pain on a background of three weeks of progressive abdominal distension, dyspnea, and significant unintentional weight loss.

We may be dealing with two overlapping timelines, an acute pain syndrome and a more subacute systemic process.

And one of the key questions early on is that are these part of the same disease process or are we dealing with two separate problems?

let us focus on acute symptoms first.

My initial priority is to consider potentially life-threatening etiologies, including both vascular and inflammatory causes.

So in the setting of JAK2 positive disease, I'm particularly concerned about thrombotic complications.

I would also keep in mind the possibility of an embolic phenomena given his atrial fibrillation.

Now, at the same time, I'm also concerned about inflammatory etiologies involving the hepatobiliary system, such as cholecystitis.

So what my initial steps would be to include doing a thorough abdominal examination.

Stepping back to the subacute picture, the progressive abdominal distension and dyspnea makes me concerned about ascites.

When approaching abdominal distension, I find it helpful to think in terms of whether this is due to solid, liquid, or gas.

And in this case, fluid seems more likely, though I would want to confirm that on physical examination.

At the bedside, I'd focus on looking for signs of ascites, such as a shifting dullness, and also assessing for hepatosplenomegaly to rule out the solid matter causes.