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PATIENT 3 - CLINICAL CASE ANALYSIS

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1. COMPLAINTS (with SOCRATES Framework)

Complaint 1: General Weakness

Complaint 2: Epistaxis (Nosebleed)

Complaint 3: Pain in the Left Shoulder Joint

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2. PATIENT HISTORY OF DISEASE

• Arrived in Tomsk for further examination of lung tumor and prostate cancer at the Oncology Research Institute.
• December 31, 2025: Episode of epistaxis, self-managed. No hypertensive crisis reported.
• Night of January 2, 2026: Collapse - wife found patient on the floor. Ambulance called.
• Taken to City Clinical Hospital No. 1 - evaluated by surgeon and therapist.
• Transferred to Regional Clinical Hospital with suspected dissecting aortic aneurysm.
• Vascular surgeon at Regional Clinical Hospital revised diagnosis to: atherosclerosis of lower extremities, occlusion of the left coronary artery, chronic ischemia grade IIA - no evidence of urgent arterial pathology.
• Transferred to duty therapeutic hospital.
• At Siberian State Medical University Emergency Department: hospitalized with diagnoses of pulmonary embolism (unspecified source), moderate anemia, community-acquired right-sided pneumonia (mild, CURB-65: 1B, DN-0).
• January 2, 2026: Red blood cell suspension A(II) Rh+ transfused - 600 ml, tolerated satisfactorily.

• Prostate cancer (known, on treatment)
• Right lung neoplasm (known)

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3. PHYSICAL EXAMINATION

• BP: 110/70 mmHg (hypotensive)
• HR: 76 bpm, pulse 76 bpm (regular)
• Respiratory rate: 20/min
• SpO2: 96% on room air (borderline low)
• General condition: Moderate

• Percussion: Pulmonary sound, symmetric bilaterally
• Auscultation: Vesicular breathing, no wheezing

• Borders of relative cardiac dullness: Left - along midclavicular line; Upper - 3rd rib; Right - 1 cm from right sternal border
• Heart sounds: Muffled, rhythmic
• No peripheral edema
• Pulsation in pedal arteries preserved

• Symmetrical, participates in respiration
• Painless on superficial palpation
• Peritoneal irritation signs: negative (Mendel, Ortner, Murphy, Mussi-Georgievsky, Kehr - all negative)
• Liver: Painless, smooth elastic edge, not below costal margin
• Spleen: Not palpable
• Kidneys: CVA tenderness negative bilaterally, not palpable

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4. PRELIMINARY DIAGNOSIS

• Pulmonary embolism (subsegmental and small branches; right S9,10; left S6,9,10) - suspected on admission based on clinical picture, elevated D-dimer, and confirmed by CT
• Deep vein thrombosis of the left leg (acute, without flotation) - thrombus at lower/upper third of leg level

• Right lung neoplasm (known; CT shows multiple lung foci and mediastinal involvement)
• Prostate cancer (known; on hormonal therapy)
• Metastatic lesions - left scapula (77x54 mm), 9th rib left, multiple bilateral pulmonary nodules (CT findings strongly suggestive)

• Moderate to severe normocytic anemia (Hgb 67-86 g/L) - multifactorial (tumor-related, epistaxis blood loss, possible chronic disease)
• Recurrent epistaxis - likely related to systemic coagulopathy/tumor-related hemostatic dysfunction

• Community-acquired right-sided pneumonia (mild, per initial assessment; resolved on follow-up X-ray)
• Atherosclerosis of the aorta and branches
• Left ventricular hypertrophy with mild dilation
• Benign prostatic hyperplasia (BPH)
• Left kidney calculus
• Reflux esophagitis; erosive antral gastropathy; duodenitis

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5. PLAN FOR INVESTIGATION (According to Standard)

For Pulmonary Embolism (PE) - Standard Workup:

For Anemia Workup:

For Lung/Prostate Malignancy Staging:

For Epistaxis / Coagulopathy:

Routine:

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6. PATIENT INSTRUMENTAL TEST RESULTS

Chest X-ray (01/02/2026):

• Decreased volume of right middle and lower lobes
• Thickening of pulmonary pattern in right basal sections - pneumonia possible
• Thickening of right interlobar fissure
• Uneven pneumatization; mixed pneumofibrosis
• Aortic thickening
• Obliteration of anterior sinuses
• Conclusion: Volume reduction of right lung (middle and lower lobes); possible pneumonia in right basal segments; LVH grade 0-1

Chest X-ray (01/06/2026):

• No focal or infiltrative changes in lungs
• Pneumofibrosis (mixed)
• Enlarged left ventricular shadow
• Aortic consolidation and atherosclerosis
• Conclusion: Resolution of prior infiltrate; pneumofibrosis; left ventricular enlargement; aortic atherosclerosis

ECG (01/03/2026):

• Horizontal electrical axis
• Sinus rhythm 86 bpm
• Frequent supraventricular extrasystoles
• Single ventricular extrasystole
• Repolarization disturbance in lead V6

ECG (01/12/2026):

• Left deviation of electrical axis
• HR 70 bpm (reduced from 86)
• No supraventricular extrasystoles
• V6 repolarization disturbance resolved

EchoCG (01/12/2026):

• Consolidated, moderately dilated aorta at Valsalva sinuses
• Mild aortic leaflet calcification with mild stenosis and mild regurgitation
• Consolidated mitral leaflets with mild regurgitation
• Abnormally located chord in left ventricle
• Tricuspid valve: moderate regurgitation
• Pulmonary artery: moderate expansion of trunk; mild regurgitation
• Moderate right ventricular dilation and increased RV systolic pressure (sign of pulmonary hypertension from PE)
• Moderate left atrial dilation
• Left ventricular hypertrophy with mild cavity dilation
• Increased echo density in inferior-septal-apical LV segments (atherosclerotic cardiosclerosis)
• LV systolic function preserved; diastolic function mildly reduced
• Pericardium unchanged

MSCT Chest with Contrast (01/15/2026):

• Left scapula: Space-occupying lesion 77x54 mm, no clear contours, cortical destruction, soft tissue extension
• 9th rib left anterior segment: Hyperdense area 8 mm without clear contours
• Left S1 bulla (7 mm)
• Multiple bilateral low-density pulmonary nodules (subpleural/perivascular): S1L (4mm), S1R (2x2mm), S2L (16x10mm with pleural strands), S3R (multiple 2mm subpleural), S6R (23x22mm, lobulated), S6L (2x up to 6mm), S9R (6mm)
• Filling defects in subsegmental and small pulmonary artery branches - S9,10 right and S6,9,10 left (CTPA confirmation of PE)
• Lymph nodes: paratracheal up to 10mm, bifurcation 7mm
• Thickened and calcified trachea/bronchi walls
• Pulmonary artery trunk 30mm wide (dilated); RPA 24mm, LPA 22mm
• Aorta 30mm; calcification throughout
• No pleural effusion; heart not enlarged
• Conclusion: Focal changes in both lungs, left scapula and 9th rib - likely metastatic; PE of subsegmental/small branches (S9,10R; S6,9,10L); aortic calcification

Abdominal Ultrasound (01/02/2026):

• Liver: No protrusion, CVR 176mm, homogeneous, normal echogenicity; S2 cyst 14mm; vascular pattern preserved
• Gallbladder: Normal
• Pancreas: Normal size, increased echogenicity (diffuse changes)
• Spleen: Not enlarged
• Left iliac region: Fluid collection 76x28x34mm (40ml) along external iliac artery - vascular integrity intact
• Kidneys: Normal position/size; left lower calyx calculus 9mm
• Bladder: 450ml, normal
• DVT (Doppler): Right leg - all veins patent, compressible. Left leg - hypoechoic thrombus in deep vein at lower/upper third of leg junction; no blood flow; apex at upper third of leg, no flotation, no superficial extension
• Conclusion: Acute DVT left leg (no flotation); fluid in left iliac region (unclear etiology); hepatomegaly; liver cyst; diffuse pancreatic changes; left renal calculus

Abdominal Ultrasound (01/16/2026):

• Liver CVR 165mm; normal echogenicity; portal vein 8mm; bile ducts normal
• Gallbladder 70x21mm with neck kink; thin walls; homogeneous contents
• Pancreas: clearly visible; head 29mm, body 18mm, tail 27mm; highly echogenic, homogeneous; Wirsung duct not dilated
• Spleen 119x50mm; unchanged
• Left iliac region: fluid accumulation 77x25x35mm, heterogeneous with suspension, no blood flow
• No free abdominal fluid
• Conclusion: Hepatomegaly; diffuse pancreatic changes (fatty infiltration); persistent fluid along left iliac vessels

Renal Ultrasound (01/16/2026):

• Right kidney 106x54mm; parenchyma 14-16mm; normal
• Left kidney 105x54mm; parenchyma 14-16mm; normal
• Left lower calyx calculus 6.5mm
• Conclusion: Left kidney calculus

Prostate Ultrasound (01/16/2026):

• Irregular shape, unclear contours; capsule not fully visible
• Peripheral fluid formation 36x35x34mm - heterogeneous with suspension, no blood flow (possible local rectal dilation vs. cystic space-occupying lesion)
• Dimensions: 49.5x34.7x41.2mm; volume 37ml (enlarged)
• Mixed echogenicity, heterogeneous structure; multiple calcifications; zones of altered echogenicity
• Enlarged transition zones: right 22x15mm, left 20x17mm; heterogeneous, unclear contours
• Seminal vesicles: width 10mm, normal echostructure
• Conclusion: Enlarged prostate with pronounced diffuse changes (BPH); peripheral fluid formation (rectal vs. cystic)

EGDS (01/13/2026):

• Esophagus: Free passage; lower third mucosa thickened, whitish, edematous, hyperemic distally; Z-line not shifted; cardia incompletely closed; gastroesophageal reflux visible
• Stomach: Normal tone; sluggish peristalsis; mucosa edematous with hyperemia foci and follicular hyperplasia in all sections; antral section shows acute elevated and complete (mature subtype) erosions 0.1-0.2cm; pylorus incompletely closed; HP urease test negative
• Duodenum: Bulb and post-bulbar mucosa with hyperemia and lymphangiectasia; normal tone; active peristalsis; bile in lumen
• Conclusion: Distal reflux esophagitis; cardia and pylorus insufficiency; erosive antral gastropathy; duodenitis

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7. SYNDROMES

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8. SCHEMATIC REPRESENTATION - LINK BETWEEN SYNDROMES

                    ┌─────────────────────────────────────────┐
                    │      ONCOLOGICAL SYNDROME (4)           │
                    │  Lung Ca + Prostate Ca + Metastases     │
                    │  (Scapula, Rib, Bilateral Lung Nodules) │
                    └──────────┬──────────────────────────────┘
                               │
              ┌────────────────┼──────────────────────────┐
              ▼                ▼                           ▼
  ┌─────────────────┐  ┌───────────────────┐   ┌──────────────────────────┐
  │ THROMBOEMBOLIC  │  │  HYPOPROTEINEMIA  │   │   INFLAMMATORY SYNDROME  │
  │  SYNDROME (1)   │  │  SYNDROME (8)     │   │        (9)               │
  │  DVT + PE       │  │  Cachexia, Low    │   │  CRP↑, ESR↑, Leukocyt.  │
  └────┬────────────┘  │  Albumin/Protein  │   └─────────────┬────────────┘
       │               └────────┬──────────┘                 │
       │                        │                             │
       ▼                        ▼                             ▼
  ┌───────────────────┐   ┌──────────────┐         ┌────────────────────┐
  │  PULMONARY HT     │   │  ANEMIC      │◄────────►│  HEMORRHAGIC       │
  │  SYNDROME (6)     │   │  SYNDROME (2)│         │  SYNDROME (3)      │
  │  RV dilation,     │   │  Hgb 67 g/L  │         │  Recurrent         │
  │  ↑RV pressure     │   │  Transfused  │         │  Epistaxis         │
  └────────┬──────────┘   └──────────────┘         └────────────────────┘
           │
           ▼
  ┌─────────────────────┐          ┌──────────────────────────┐
  │  CARDIOVASCULAR     │          │  GASTROINTESTINAL        │
  │  SYNDROME (5)       │          │  SYNDROME (7)            │
  │  LVH, Atheroscl.    │          │  Reflux, Erosive         │
  │  LCA occlusion      │          │  Gastropathy, Duodenitis │
  └─────────────────────┘          └──────────────────────────┘
                                          ▲
                                          │
                              ┌───────────────────────┐
                              │   UROLOGICAL SYNDROME  │
                              │        (10)            │
                              │  Renal Calculus, BPH,  │
                              │  Bacteriuria           │
                              └───────────────────────┘

• Malignancy (oncological syndrome) drives hypercoagulability (Trousseau syndrome) → thromboembolic syndrome (DVT + PE)
• PE → increased pulmonary vascular resistance → pulmonary hypertension → right heart strain
• Malignancy + bleeding (epistaxis) + bone marrow infiltration/suppression + iron deficiency → anemic syndrome
• Tumor-related coagulopathy (DIC-like state with elevated D-dimer and fibrinogen) → hemorrhagic syndrome (bleeding) AND thrombosis simultaneously
• Cancer cachexia → hypoproteinemia → worsens anemia, impairs healing
• Systemic inflammation from tumor + infection → inflammatory syndrome
• Pre-existing atherosclerosis (independent) + LVH → cardiovascular syndrome (separate but worsened by anemia and hypoxemia from PE)

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9. FINAL DIAGNOSIS

Main Diagnosis:

Background Disease:

1. Malignant neoplasm of the right lung (T-N-M staging not fully specified; CT: multiple bilateral pulmonary nodules, mediastinal lymphadenopathy)
2. Prostate cancer (on hormonal therapy with Casodex/bicalutamide)
3. Metastatic bone disease - left scapula (77x54 mm, cortical destruction), 9th rib left - likely secondary (metastatic) in nature per CT conclusion

Complications:

1. Anemia of moderate severity (Hgb nadir 67 g/L) - multifactorial: post-hemorrhagic (epistaxis), chronic disease (cancer-related), possible bone marrow infiltration; normocytic/slightly macrocytic (MCV 96-99 fL)
2. Recurrent epistaxis - associated with coagulopathy in the setting of malignancy (DIC-like state, elevated D-dimer 4136 ng/mL)
3. Secondary pulmonary hypertension with moderate right ventricular dilation and elevated RV systolic pressure

Concurrent Diagnoses:

1. Coronary artery disease - atherosclerotic cardiosclerosis; occlusion of the left coronary artery; chronic ischemia grade IIA
2. Left ventricular hypertrophy with mild cavity dilation; mild diastolic dysfunction; moderate left atrial dilation
3. Atherosclerosis of the aorta and branches (calcification confirmed on CT and X-ray)
4. Community-acquired right-sided pneumonia - mild course (CURB-65: 1B); resolved on follow-up X-ray by 01/06/2026
5. Diffuse reflux esophagitis (distal), cardia and pylorus insufficiency, erosive antral gastropathy (HP-negative), duodenitis
6. Benign prostatic hyperplasia (BPH) with pronounced diffuse prostate changes
7. Left kidney calculus (6.5 mm, lower calyx group)
8. Urinary tract infection (bacteriuria, transient leukocyturia)
9. Diffuse pancreatic changes (fatty infiltration type, per US)
10. Liver cyst (S2, 14mm)

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Clinical Note: Anticoagulation for PE/DVT was temporarily withheld due to recurrent epistaxis and severe anemia, representing a high-risk management dilemma. Reinstatement of anticoagulation was to be decided once hemostasis stabilized - a common challenge in cancer-associated thromboembolism with concurrent bleeding.

COMPLETE BLOOD COUNT (CBC) REPORT - Patient 3

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CBC Results Across All Time Points

01/02/2026 - Admission CBC

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01/03/2026 - Day 1 Post-Transfusion CBC

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01/04/2026 - Follow-up CBC

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01/08/2026 - Extended CBC with Differential (CRITICAL)

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01/12/2026 - Extended CBC with Differential

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01/15/2026 - Final CBC Before Discharge

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CBC Trend Summary (Hemoglobin & Key Parameters)

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CBC Interpretation & Clinical Analysis

1. Anemia - Characterization

• Post-hemorrhagic (recurrent epistaxis + acute blood loss)
• Anemia of chronic disease / cancer-related (CRP 110 mg/L, malignancy)
• Iron deficiency component (low serum iron)
• Possible bone marrow infiltration by metastases (nucleated RBCs on 01/12, elevated IG%)

2. Leukocyte Analysis

3. Platelet Analysis

4. ESR

• Markedly elevated: 78 mm/hr (01/12), 71 mm/hr (01/15)
• Normal: 0-20 mm/hr
• Consistent with: active malignancy, systemic inflammation, severe anemia, hyperproteinemia (fibrinogen 4.5-5.22 g/L)

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Overall CBC Conclusion

This CBC series documents severe normochromic normocytic anemia (Hgb nadir 67 g/L) with evidence of a leukoerythroblastic response (immature granulocytes, nucleated RBCs), anisocytosis, markedly elevated ESR, reactive leukocytosis at admission resolving over time, and normal platelet counts throughout. The pattern is consistent with multifactorial anemia in the setting of advanced malignancy (lung cancer + prostate cancer with bone metastases), compounded by acute hemorrhage (epistaxis) and anemia of chronic disease. The leukoerythroblastic changes raise concern for bone marrow infiltration by metastatic disease. Partial recovery of hemoglobin (67 → 108-109 g/L) followed RBC transfusion but anemia persisted at discharge, confirming an ongoing underlying cause rather than isolated acute blood loss.