WELCOME TO GRAND ROUND PRESENTATION.
A 45-YEAR-OLD woMAN with deep jaundice. Dr. Shahima Islam Core Medical Trainee Medicine Unit – VI DMCH.
CASE SUMMARY.
CASE SUMMARY.
CASE SUMMARY. She also complained of multiple blister like skin lesions of different size & shape for last 3weeks. At first they appeared at trunk & then at extremities, but did not involve face or mucous membrane. Lesions were more on upper chest, abdomen and inner aspect of left leg ..
CASE SUMMARY. Those were itchy and contained clear fluid initially. Then became pustular, tensed and healed by crusting. On query She also complained of generalized fatigue which remained throughout the day with no diurnal variation. It was not associated with any exertional dyspnea. She also complained of weight loss evidenced by loosening of clothes ..
CASE SUMMARY. She also noticed changes of her skin color day by day with generalized itching. Itching was present throughout the day & night, which was more intense in the limbs . It was not related to any food, allergen or any drug and not associated with any rash..
CASE SUMMARY. She also complained of low back pain for last 1year. Pain was dull in nature , moderate in intensity, localized, non radiating, aggravated by walking and relieved by taking rest and NSAID. Pain was not associated with tingling & numbness or morning stiffness . She denied history of any other joint involvement..
CASE SUMMARY. She also complained of occasional passage of voluminous, pale, foul smelling stool for last 1 year which was not mixed with blood or mucus & any pain during defecation..
CASE SUMMARY. There is no history of fever, photosensitive rash , alopecia , mouth ulcer, dryness of mouth or eye, tightening of skin, cold intolerance, somnolence, melaena, hematemesis, scanty micturition , abdominal pain or leg edema..
CASE SUMMARY. She denied any history of blood transfusion, previous surgery, tattooing or any significant drug history. She gave no travel history or any extramarital sexual exposure. She has 3 children. All of them are in good health. None of her family member is suffering from such disease..
CASE SUMMARY. She belongs to middle class family & used to take normal diet. She is menopausal for 1 year. Before that she had a normal menstrual cycle. She is immunized as per EPI schedule & vaccinated against COVID-19. She has no psychiatric illness..
PHYSICAL EXAMINATION.
Appearance: ill looking Anemia : moderately anemic Body built: average Jaundice : deeply icteric Co-operation: co-operative Cyanosis: absent Decubitus: on choice Clubbing: absent Nutritional Status: Below Koilonychia: absent average Leuconychia : absent BMI: 17.5 kg/m2 Edema: absent.
Dehydration: absent Skin condition : multiple crusted skin lesion present on upper chest , mammary fold , abdomen , inner aspect of left leg. Xanthelasma: present . Hair distribution : normal ..
GENERAL EXAMINATION contd.. Thyroid gland: not enlarged . Lymph node: no lymphadenopathy. Sternal tenderness: absent Flapping tremor : absent..
Lesion in mammary fold:.
Jaundice & xanthelasma:.
GENERAL EXAMINATION CONTD.. Pulse : 66 b/min Blood pressure : supine:100/60 mmHg with no postural drop. JVP : normal Respiratory rate: 22 bp/min Temperature: normal Bedside urine dipstick test: negative for protein and sugar.
Alimentary System Examination. ORAL CAVITY : Buccal mucosa, Lips, gums, palate were normal. No pigmentation was present in oral cavity. ABDOMEN PROPER : Abdomen was normal in shape. Flanks were empty. Umbilicus was centrally placed, inverted, vertically slit. No visible peristalsis and no scar mark except for scratch marks from itching..
Alimentary System Examination cont.. PALPATION: Temperature: Normal. Tenderness: Absent. Hepatomegaly was present which is 3 cm from right costal margin along the mid clavicular line. Non tender, firm in consistency , smooth surface, regular margin . There was no hepatic bruit . upper border of liver dullness present in 5 th intercostal spaces along the mid clavicular line..
Alimentary System Examination cont …. No other organomegaly was present. Para aortic and inguinal lymph nodes were not palpable. PERCUSSION: Percussion note: Tympanitic. AUSCULTATION : Bowel sound: Present..
Cardiovascular System Examination. Inspection : No visible apex beat. Visible scar mark. Palpation : Apex beat located in left 5 th ICS, just medial to the midclavicular line. No thrill present. Auscultation : S1 and S2 was normal and no added sound - Bilateral lung bases were clear.
musculoskeletal System Examination. On spine examination : Spinal tenderness present over 1 st lumber vertebrae. All modalities of movement is mildly restricted due to pain.
NERVOUS SYSTEM EXAMINATION. GCS: 15/15 Orientation: Oriented to time ,place and person Speech: Intact Memory: Intact Cranial Nerves: Intact Signs of Meningeal Irritation: Absent.
MOTOR – LOWER LIMB. Parameter Right Left Bulk Normal Normal Tone Normal Normal Power 5/5 5/5 Knee Jerk Present Present Ankle Jerk Normal Normal Planter Flexor Flexor.
MOTOR-UPPER LIMB. Parameter Right Left Bulk Normal Normal Tone Normal Normal Power 5/5 5/5 Biceps Jerk Present Present Triceps Jerk Present Present Supinator Jerk Present Present.
NERVOUS SYSTEM EXAMINATION CONTD. Sensory Assessment: All modalities of sensation were intact. Cerebellar Function: Intact Fundoscopic Examination: No abnormality..
OTHER SYSTEMIC EXAMINATIONS. Examination of other systems revealed no abnormalities ..
45 year old woman 1.Xanthalesma 2. Hepatomegaly 1.Blister like skin lesion. 2.Deep jaundice 3.Fatigue 4.Itching 5.Low back pain..
PROVISIONAL DIAGNOSIS ?.
PROVISIONAL DIAGNOSIS. PRIMARY BILIARY CHOLANGITIS WITH BULLOUS PEMPHIGOID.
DIFFERENTIALS. Autoimmune hepatitis. Primary sclerosing cholangitis..
INVESTIGATION PROFILE.
CBC. Parameters Result Reference Value Hemoglobin 7.5 g/dL 13-17 g/dL RBC 2.4 million/ cumm 4.5-5.5 ESR 48 Reticulocyte count 7.38% HCT 22.4% 40-52% MCV 76fl 83-100fL MCH 25pg 27-32 pg MCHC 33.1g/dL 30-35 g/dL WBC 17000/ cumm 4000-11000 PLATELET 180000/ cumm 150000-450000.
PeriPHeral blood film :. Microcytic hypochromic anemia ..
investigation coNTD.. TEST RESULT S.Iron 42 micro g/L S.Ferritin 1132 ng/ml TIBC 304 micro g/l.
investigation contD.. TEST RESULT Coomb’s test ( Direct) Negative Coomb’s test ( Indirect) Negative.
investigation cont.... TEST RESULT REFERENCE VALUE A LP 1540 U/L 46-116U/L ALT 291 U/L 10-49U/L S. Bilirubin (Total) 33.1mg/dL 0.2-1.2 mg/dl S. Bilirubin (direct) 22.5 mg/dl 10.6mg/dl.
Investigation cont .... TEST RESULT CRP 33 mg/L S.Albumin 2.93 mg/dl S.Albumin : S.Globulin 0.77 S. LDH 477 U/L.
investigation cont... TEST RESULT REFERENCE VALUE Prothombin time 16 sec 10-12 sec Bleeding Time 03 min 45 sec Up to 5 sec Clotting Time 05min 10 sec upto 11 sec.
investigation cont... TEST RESULT REFERENCE VALUE S. cholesterol 310 mg/dl 150-200 mg/dl HDL-Cholesterol 52 mg/dl F>65 mg/dl LDL-Cholesterol 200 mg/dl <150 mg/dl S.Triglyceride 319 mg/dl 50-150 mg/dl.
URINE RME. PARAMETERS RESULT PUS CELL 4-5 /HPF RBC /HPF NIL SUGAR NIL ALBUMIN NIL KETONE BODIES ABSENT CASTS NIL REACTION (pH) ACIDIC.
investigation cont... TEST RESULT REFERENCE VALUE ELECTROLYTE Serum Sodium Serum Potassium Serum Chloride 143 mmol/L 4.6 mmol/L 99mmole/L 135-145mmol/L 3.5-5.5 mmol/L 95-105mmole/L Serum Creatinine 0.83 mg/dL 0.6-1.2 mg/dL RBS 6.2 mmol/L <7.8 mmol/L.
investigation cont... TEST RESULT HBsAg Negative Anti HCV Antibody Negative.
Usg of whole abdomen :. Mild hepatomegaly. Contracted gallblader. Suspected lymphadenopathy at portal hepatis..
UPPER GI ENDOSCOPY. Upper GI Endoscopy Congestive gastropathy..
Chest X-ray PA View : Normal. 'MONOWARA BEGuM CHEST PA VIEW.
X-ray of lumber region both view: shows collapse of 12 th thoracic vertebra..
Bone densitometry :. T he BMD measured at AP spine L1-L4 is 0.584 g/cm2 with T-score of -4.9 T he BMD measured at Femur neck Lt is 0.469 g/cm2 with T-score of -4.1 The BMD measured at Femur neck Rt is o.520 g/cm2 with T-score of -3.7 The BMD measured at femur total Lt is 0.497 g/cm2 with T-score of -4.1 The BMD measured at femur total Rt is 0.522g/cm2 with T-score of -3.9..