Elog-general medicine

25th November 2020

55 yr old Male with

Pain with abdomen since 3 months

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CASE PRESENTATION:

This is a history of a 55 year old Male, farmer

 by occupation came with chief complains of

C/o pain in abdomen since 3month

C/o distention abdomen since 3 months

C/o yellowish discoloration of urine and eyes since 2 months

C/o loss of appetite and c/o weakness

Patient was apparently asymptomatic 3 months back then developed pain in abdomen in Rt lumber and Rt hypochondrium which is insidious in onset, rapidly progressive in nature ,burning type of pain, radiating to epigastrium and retrosternal region aggravated on eating food and relieved on taking medication.

Pain was persistent through out the day relieved only on taking medication was on ''TRAMADOL INJ'' Since 3 months .

H/O icterus since 2 months,gradually progressive.

C/o vomiting 1 episode , 2 days back, non-bilious,no hematemesis.

C/o nausea

No h/o passing stools since 2 days ,passing flatus

No h/o bleeding per rectum

No h/o significant loss of weight 

Loss of appetite present

No h/o fever associated with pain

No h/o high coloured urine/clay coloured stools

Not a known case of diabetes and hypertension.

No history of TB, epilepsy, thyroid and asthama.

No h/o previous surgeries. 

Decrease appetite 

Mixed diet

Sleep adequate

Irregular bowel and bladder movements 

Not passing stools since 2 days

Smoker- tobacco (6 beedis) per day since 20 years.hm H/o kaini consumption 

Alcoholic since 7 years 

No known allergies. 

 

General examination:-

Patient is conscious,coherent and cooperative

Thin built and poorly nourished 

 

No pallor, clubbing, cyanosis, lymphedenopathy, edema

Icterus present since 2 months

Temperature-98.2F

Bp- 100/60mmhg

PR- 86bpm

RR- 32cpm

Sp02- 99%

GRBS - 126mg/dl 

 SYSTEMIC EXAMINATION:-

P/A :- shape- scaphoid,umbilicus - central,  soft,tenderness in Rt hypochondrium and umbilical region. Non-distended. NO Organomegaly, tennis ball like mass palpable on deep inspiration. 

 

CVS - S1S2 +,no murmurs

RS - BAE+,NVBS+

CNS - intact

Referred to surgery for pain in abdomen and     mass in abdomen on rt hypochondrium and rt lumber region.

Advice: 

1)  inj.vit k 1 amp IM OD 3days

2) start antibiotics if patient develops any signs of cholangitis (fever,chills and rigors)

REFERRED TO PSYCHIATRY

THIS IS A CASE 53 YEAR OLD MAN COMPLAINTS OF OBSTRUCTIVE JAUNDICE SECONDARY TO CBD sticture secondary to ig4 related disease [?primary sclerosing cholangitis] referred to us i/v/o stress 

complaints low mood occasionally -10 years

pain abdomen pervasive low mood -3months

patient was apparently asymptomatic 10 yrs  back when he got to know that his daughters husband does not take care of her he keeps taunting her that she belongs from not a very well to do family and even beat her once or twice infront of her

pts wife also has medical comorbidities ie htn and he constantly thinks about it he did not get his share of land from ancestral property 

his in laws do not respect him as he has an alteration with them regarding patient being not much educated to move with them in society

due to the above stressor there is resriction in patients lifestyle he does not mingle with everyone, he has fear of being rejected in social situations,he believes that he is socially unacceptable,person inferior to others, avoids social activities(anxious avoidant personality). Even though his son has completed BED he couldn't find a job till now as government not conducting exam since 2016.

stresser+(family ,personal,financial)

patient says whenever he would get these thoughts he would feel low for sometime,not associated with crying spells,suicidal ideations, was going to work regularly,self care with hygiene was maintained.

since past 3 1/2 months pt started complaining of pain abdomen which was gradual in onset and progressive so he stopped going to work since then ,keep to himself,does not talk with his friends also,responds to them only when they come home and ask about his health,he cries occationally due to pain and even thinks about all the previous stressors in his life . he prefers staying alone most of the time. Thinks that his son is not care of him .Not seeing TV like before. whenever pain would increase(mostly during evenings)he would cry..2 months back he wanted to commit suicide by hanging(due to severity of pain)no attempt was made as he thought about wife and kids . No active suicidal adeations currently. sleep & appetite decresed. Pt has visiteda few doctors in behar,where UGJE showed duodenal ulcer and LFT showed raised bilirubin of 5.48 on 18-11-20. After which he was brought to KIMS narketpally and was admitted .Reports 80% improvement (pain decreased).

h/o tobacco use since 15 yrs, smoking 10 beedis/day occassionally stopped smoking since 3 1/2 months due to abdominal pain.

No h/o HTN,DM,head injury,seizures,LOC.No h/o any substance use,no h/o self talking,self smiling,suspiciousness.

No h/o repetitive thought, actions,no h/o grandiosity

MSE:GAB-pt came along with son and nephew

thin built,moderately nourished

Icterus+

ETEC + and sustained PMA normal ,rapport established (as pt does not understant hindi tranlator was present during interview)

speech normal ,RT normal relavant and coherrent

mood- teekhai , Affect -anxious, Thought-preoccupied with pain, Perception-NAD

PT is oriented to time/place/person

IMPRESSION: MODERATE DEPRESSON due to underlying stress or secondary to medical morbidity

TREATMENT ADVISED: Psychotherapy

T.NICOTEX 2MG SOS

T.AMITRIPTYLINE 20MG &

T.PREGABA 150MG

INVESTIGATIONS:-

LFT :-

TB- 10.38

DB- 6.01

AST - 86

ALT - 150

ALP - 909

TP - 6.1

Alb- 3.7

A/G ratio - 1.56

Hemogram:-

Hb - 10mg/dl

Tc - 8200 cells/cumm

PC - 1.4 lakhs/cumm

Serology- negative

Day1

 

 

 

 

Ultrasound abdomen:

 

Ultrasound Review:

Chest xray PA view:

Ecg:

 

Chest x ray erect abdomen:

 

Endoscopy:

 

MRCP:

 

 

 

 

 

CECT

 

 

Day 8th

Referral to oncology

 

Reffered to gastroenterologist:

He presented with pain abdomen,icterus,loss of appetite with investigations done outside showing

Dilatation of cbd, multiple duodenal ulcers,

First endoscopy was done to look for obstruction in the second part of duodenum and growth beneath the ulcers, no such findings reported

Then mrcp was planned to look for area of obstruction,mainly the periampullary area, findings suggested a narrowing of cbd duct at it's terminal part and abnormal dilatation, 

Surgical oncologist was consulted , and triple phase ct was adviced to see the presence of lymphadenopathy, and extent of local invasion for ? cholangiocarcinoma which was our working diagnosis

CT revealed a stricture  at the terminal part of cbd with no evidence of growth , lymphadenopathy, which led us to our current differentials of 

? primary sclerosing cholangitis

? cholagiocarcinoma

IgG4 related disease.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5953192/Treatment of IgG4 Related disease

DIAGNOSIS:

Obstructive jaundice 2°  to CBD stricture

2° to IgG4 Related disease

? primary sclerosing cholangitis

TREATMENT:-

In a retrospective, multicenter study of 25 IgG4-RD patients in France, prednisone at a starting dose of approximately 47 mg/day (0.67 mg/kg for a 70-kg patient) was effective in controlling the disease in 90% of patients. In that study, treatment response was defined by the presence of at least two of the following features: improved clinical status, reduction in serum IgG4 concentration, and improved radiologic findings. Even higher response rates have been reported in autoimmune

Day1

1) T.ultracet PO QID

2)T.Prababilin  75mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.Voveran 2cc IM sos

Day2,3

1) T.ultracet PO QID

2)T.Pragabalin  75mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.Voveran 2cc IM/sos

 6)Mucaine gel 15ml PO/TID/15mins after food

                      7) Inj .Pantop 40mg IV/BD

   

   

Day 4

 

1) T.ultracet PO QID

2)T.Pragabalin  75mg PO/OD

3)T. Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.Voveran 2cc IM/sos

 6)Mucaine gel 15ml PO/TID/15mins after food

   7) Inj .Pantop 40mg IV/BD

   8) I/O charting

9)temperature, BP, PR 4th hourly monitoring

           10)GRBS 6th hourly monitoring 

 

  Day 5

 

1) T.ultracet PO QID

2)T.Pragabailin  75mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.Voveran 2cc IM/sos

 6)Mucaine gel 15ml PO/TID/15mins after food

   7) Inj .Pantop 40mg IV/BD

   8) I/O charting

9)temperature, BP, PR 4th hourly monitoring

  10)GRBS 6th hourly monitoring 

Day 6,7,8

1) T.ultracet PO QID

2)T.Pragabailin  75mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.Voveran 2cc IM/sos

6)Mucaine gel 15ml PO/TID/15mins after food

7) Inj .Pantop 40mg IV/BD

8) I/O charting

9)temperature, BP, PR 4th hourly monitoring

10)GRBS 6th hourly monitoring 

  

Day 9

1) T.ultracet PO QID

2)T.Pragabailin  150mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.buscopan 2cc IM sos

6)Mucaine gel 15ml PO/TID/15mins after food

7) Inj .Pantop 40mg IV/BD

8) I/O charting

9)temperature, BP, PR 8th hourly monitoring

10)GRBS 12th hourly monitoring 

Day 10,11,12

1) T.ultracet PO QID

2)T.Pragabailin  150mg PO/OD

3) T.Amitriptylline 20mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.buscopan 2cc IM/sos

6)Mucaine gel 15ml PO/TID/15mins after food

7) Inj .Pantop 40mg IV/BD

8) I/O charting

9)temperature, BP, PR 12th hourly monitoring

10)GRBS 12th hourly monitoring 

Day 14

1) T.ultracet PO QID

2)T.Pragabailin  75mg PO/OD

3) T.Amitriptylline 10mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.buscopan 2cc IM/sos

6)Mucaine gel 15ml PO/TID/15mins after food

7) Inj .Pantop 40mg IV/BD

8) T.Prednicolone 40mg PO/OD-day 1

9)temperature, BP, PR 12th hourly monitoring

10)GRBS 12th hourly monitoring 

   Day 15-24

1) T.ultracet PO QID

2)T.Pragabailin  150mg PO/OD

3) T.Amitriptylline 20mg PO/HS

4) inj.tramadol 1 amp in 100ml NS/IV/slow

5) Inj.buscopan 2cc IM/sos

6)Mucaine gel 15ml PO/TID/15mins after food

7) Inj .Pantop 40mg IV/BD

8) T.Prednisolone 40mg D2-11

9) T.Nicotex gums 2mg sos( whenever pt experiences craving for tobacco

10)temperature, BP, PR,GRBS 12th hourly monitoring