62/F came to casualty with c/of pain abdomen since 1 month 
Yellowish discoloration of eyes since 15 days 
Vomitings since 15 days
sob since 15 days 
Decreased appetite since 15 days
Patient was apparently asymptomatic 1 month back 
Had H/of pain abdomen on and off since 1 month - insidious onset, intermittent , diffuse and burning type of pain associated with decreased appetite taking only fluids since 15 days f/by vomitings - bilious, non- projectile, food or water as content whenever patient is taking oral feeds
Yellowish discoloration of eyes since 15 days 
Sob since 15 days inscidious onset gradually progressed from grade 2 to 3 associated with pedal odema and decrease urine output 
not associated with fever, cold, cough, orthopnea and PND
No pale coloured stools, mucous , blood or dark coloured stools 
0/examination: pt-conscious and tachypnic 
Afebrile 
Icterus + 
No pallor, cyanosis, clubbing, lymphadenopathy
PR - 90 bpm 
BP- 130/80 mm of hg 
RR - 34 cpm 
Spo2 -88 with RA 
98 with 2 L of oxygen
GRBS : 85 mg /dl
R/S : fine crepts + in B/L IAA ,ISA 
Decreased breath sounds in right IAA and ISA 

CVS - S1 and S2+
P/A - soft, tenderness + in epigastric region , right hypochondrium and umbilical region 
R/S : fine crepts + in B/L IAA ,ISA 
Decreased breath sounds in right IAA and ISA 

CVS - S1 and S2+ 
CNS - NAD

INVESTIGATIONS
Abg:
Usg abdomen
Cxr

X ray erect abdomen

Pleural fluid

Ascitic fluid
MRCP :
Pleural fluid:
 sugar:56
Proteins:3.7
LDH :409
Albumin:2.2
Amylase 8.7

Ascitic fluid:
sugar:49
Proteins:3.8
LDH :605
Albumin:2.2
Amylase 23
Saag :0.2
CT abdomen:
Referrals:
Surgery referal
gastroenterology referal
Ent referal

Diagnosis:
Obstructive jaundice secondary to CBD stricture/cholangio carcinoma

Popular posts from this blog

Image
54 YEAR OLD MALE PATIENT WITH DISTENTION OF ABDOMEN, JAUNDICE, BURNING MICTURITION SINCE 15 DAYS   This is an online E Logbook to discuss our patient's de-identified health data shared after taking his/her guardian's signed informed consent. Here, we discuss our individual patient's problems through a series of inputs from an available global online community of experts to solve those patients' clinical problems with collective current best evidence-based inputs. This e-log book also reflects my patient-centered online learning portfolio and your valuable inputs in the comment box are welcome. —————————————————————————————————————————————- A 54 YEAR OLD MALE  PATIENT CAME WITH COMPLAINTS OF  1. DISTENSION OF ABDOMEN SINCE 15 DAYS 2. H/O JAUNDICE SINCE 15 DAYS 3.BURNING MICTURITION SINCE 15 DAYS NO H/O FEVER,SOB,PEDAL EDEMA HOPI:  PATIENT WAS APPARENTLY ASYMPTOMATIC 5 MONTHS BACK, ON JAN 2021 PATIENT WAS OPERATED FOR GALL STONES.POST OP NO COMPLICATIONS AND WAS NORMAL .
Read more
Image
62 year old male with loss of appetite,sob and fever   CBBLE UDHC similar cases  THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE - IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT .HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS WITH AN AIM TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUT  62 year male farmer by occupation came with complaints of loss of appetite since 20 days ,sob and fever, since 20 days. Vomiting since 2 days. ,Painful swelling in the left  gluteal region since 2 days and pain in the right hip region HOPI : patient was apparently asymptomatic 20 days back then he went to outside private hospital with complaints of fever and sob and on investigation his creatinine 5.3 ,so sent for hemodialysis to our hospital. C/o shortness of breath since 20 days  grade 4 ,no pnd and no orthopnea Fever treated at
Read more
A 35 YR OLD MALE PATIENT WITH DKA This is online E-blog, to discuss our patient de-identified health data shared after taking her guardian's signed informed consent.Here we discuss our individual patient problems through series of inputs from available global online community of experts with an aim to solve the patients clinical problem with current best evidence based input. This E-blog also reflects my patient's centred online learning portfolio. I have been given this case to solve in an attempt to understand the topic of "Patient Clinical Data Analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. Complaints of shortness of breath since two days on and off increased since morning  complains of fever since two days  complains of burning micturition since two days HOPI Patient was apparently a symptomatic five years back then he was diagnosed
Read more