Medicine E-log

CASE- A 50 year old male patient who was was apparently asymptomatic 45 years back.

HISTORY OF PRESENTING ILLNESS- 

H/o trauma to his right eye at the age of 5 during a kite festival which led to loss of vision in that eye.

10/2019 : He noticed gradual discolouration of urine turning more and more yellowish 5 months back, followed by yellowish colouration of eyes (intermittent jaundice) followed all over body accompanied with itching.

Loss of appetite present.

Fatigue present.

Melena present since 3 months.

Fever since 1 month associated with chills and rigors.

No history of burning micturition.

[Additional patient complaints/observations: if he takes food in the night he says he is passing yellowish urine and if he doesnt take food in the night his urine appears white and stools always remained black irrespective of food.]

PAST HISTORY- While he was passing yellowish urine which he mistook for not drinking enough water he increased his fluid intake which provided no relief. He then visited a hospital (after 2 months) was  diagnosed with obstructive jaundice and took treatment for 10 days (bilirubin levels came down from 7 to 3mg/dL) 

History of traditional medication taken for treatment which were stopped later on.

H/o of weight loss from 10 kilos (from 50kgs to 40kgs) in a span of 2 months (Oct- Nov).

H/o sputum expectoration- white, non-foul smelling (on and off)

Loss of appetite present.

Pain abdomen present.

No H/o burning micturition

H/o blood transfusions 2PRBC (two units on the same day in December)

Not a known case of DM, HTN, epilepsy, thyroid ,TB 

PERSONAL HISTORY

Diet- Mixed

Appetite- Decreased

Sleep- Adequate 

Bowel- Melena

Bladder- Discolouration of urine (Yellow)

Non-alcoholic, non-smoker, occasional betel nut chewer.

O/E:

Pt c/c/c

Pallor +, icterus + 

SYSTEMIC EXAMINATION:

I.ABDOMEN-

Shape = scaphoid

Soft, tenderness present in right hypochondrium, epigastrium

All quadrants moving equally with respiration

Hernial orifices are full

Umbilicus everted

No organomegaly detected

Bowel sounds heard

II.RESPIRATORY SYSTEM:

BAE +

NVBS heard

III.CNS EXAM:

Higher mental functions- normal

Cranial nerves- intact

Motor system- normal

Sensory system- normal

IV.CVS EXAMINATION:

1. PULSE: 80bpm, regular

2. BP= 90/50mmHg

3. Neck veins examination= not engorged

INVESTIGATIONS

Haemogram

Hb :2.7 gm%

TLC 7500

Plt- 2.82 lakhs 

LFT:

TB - 5.19

DB - 2.10

SGOT - 49

SGPT- 33

Alp - 673

TP-4.8

Albumin -2.0

A/G- 0.75

RFT

Urea -30

Creatinine-0.7

UA - 5.0

Ca-9.2

PO4 -3.1

Na - 138

K-3.0

Cl-102

HCV- NEGATIVE

HbsAG NEGATIVE

HIV NON REACTIVE

CUE:Albumin-trace,sugars-nil,puscells-3-4,epithelial cells-2-3

USG ABDOMEN: IHBRD dilatation with dialted CBD and 15*14 mm in terminal CBD 
The investigations performed in the order of their timeline are given below

HISTOPATHOLOGY IMAGES:

(Duodenal Biopsy)

ENDOSCOPY IMAGES:

Based on the above investigations and the history provided the provisional diagnosis is Cholangiocarcinoma with obstructive jaundice.

TREATMENT:
1. Tab. Orofer XT BD
2. Egg white 4/day
3. ProteinX powder
4. Tab. PCM 650mg SOS
5. Tab. Avil 12.5mg TID