A 60-year-old White woman presents to her primary care provider reporting fatigue, decreased appetite, abdominal pain, nausea, and vomiting. She reports a 25-lb weight loss in the last month. She is 5 ft 6 in and went from 140 lb (BMI of 22.6) to 115 lb (BMI of 19.4).
The patient appears tired, pallid, and slightly jaundiced. Physical exam reveals normal vital signs and regular heart rate and rhythm. Her lungs are clear to auscultation bilaterally. Her abdomen is slightly distended and tender to palpation in the right upper quadrant. She has a negative Murphy sign. She has left axillary lymphadenopathy.
The patient has a positive family history for breast cancer, with both her mother and sister diagnosed at ages 62 and 63 years old, respectively. Otherwise, the patient's medical history is unremarkable. She is a non-smoker and rarely consumes alcohol.
Laboratory testing reveals WBC of 13,000 mm3; ALP of 140 IU/L; AST of 80 IU/L; ALT of 100 IU/L; total bilirubin of 1.2 mg/dL; and hemoglobin of 15 g/dL.
Because of the patient's positive family history, she is sent for screening mammography that identifies a 2.2-cm mass in the upper outer quadrant of the left breast. MRI reveals axillary lymph node involvement as well as multiple lesions on the liver.