Category Archives: CASE

Liver enlargement

yesterday we were confronted with a patient with the following complains

60 yo man,married,ex smoker, smoked for 35 years

c/o: rt hypochonrium pain, 4 years ago, present all the time, it was stitching pain gradually increasing by time, unrelated to food intake, radiate to both should, aggraveted by lying on his right side and by inspiration, and disappeared during expiration. after 1 y he complains the dyspnea, cough with sputum.
constipation: since 1.5 years. dark brown
urine: tea colored urine

loss weight as much as 10 kg over the past 1.5 years. no fever

( i wanted to analyse the dyspnea and cough but my colleagues ‘assumed’ that it wasnt dyspnea but rather due to the diseased liver. i hesitated this assumption . however since we were running out of time, i didnt analyse further. it turns out that the patient has bronchial carcinoma . so the lesson learnt here , its a mistake to assume a patients complaint and exclude it without analysing. such details may lead us to important findings)

how to dd tea colored urine due to hematuria or presence of bile without lab investigation?
leave the urine in a container for some time and in hematuria, there will be sediments of RBC at the bottom.

if you see a jaundice patient DONT FORGET TO ASK/FIND ABOUT
urine and stool
Tremors
spider angioma
evidence of hemolysis
gynecomastia
oedema
PRURITIS!!!!!!!(obstructive jaundice)
clubbing
alcohol intake!!!!!
blood transfusion!!!!!!(source of hepatitis/ mismatched blood)

in liver failure there is hyperestrogenemia due to?INCREASE CONVERSION OF TESTOSTERONE TO ESTROGEN DUE TO INCREASE IN SEX BINDING HORMONE.
i was always told that hyperestrogenemia is due to failure of metabolism of estrogen due to the impaired liver function. both can be correct i guess?

postive findings: enlarged liver and spleen. State the span of the organs!

during palpation the first thing you have to notice or note at is the tenderness!! look at your patients in the eye!!!

alkaline phosphatase

In humans, alkaline phosphatase is present in all tissues throughout the entire body, but is particularly concentrated in liver, bile duct, kidney, bone, and the placenta

High ALP levels can show that the bile ducts are blocked.[11] Levels are significantly higher in children and pregnant women. Also, elevated ALP indicates that there could be active bone formation occurring as ALP is a byproduct of osteoblast activity (such as the case in Paget’s disease of bone)

Placental alkaline phosphatase is elevated in seminomas[12] and active form of Rickets.-wiki

in this patient, hi level suggests obstruction in the biliary ducts. do GGT to know the source of the hi ALP.

The main value of GGT over ALP is in verifying that ALP elevations are, in fact, due to biliary disease; ALP can also be increased in certain bone diseases, but GGT is not. – wiki source

pssst: Aldactone can also cause gynecomastia!!!!

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crohn’s , diarrhea

1st day in git.

CASE 1: CROHN’S DISEASE

our case for today was a man of 50 y of age complaining of chronic diarrhea since 1 y 2 m .he complained of diarrhea at first, and then it was followed by diarrhea with streaks of blood and mucous, also diffuse abdominal pain. not related to eating. irrelevant family history. he had thyroid mass before and did an operation beforehand. also there was nocturnal diarrhea

dx: crohns disease.

ok what i want to ask if i had more time.analyse the abdominal pain. was there vomiting? did he suffer similar conditions before? how frequent did he defecate? consistency of stools? colour? was it fresh blood? any other complains?( think of the extraintestinal manifestations of IBD). effect of fasting( osmotic diarrhea stops but secretory diarrhea persists)?of course drug history is essential( think of antibiotics, laxatives, toxics) other associated diseases? diseases in other systems? ( DM- autonomic neuropathy, endocrinal- hyperthyroidism,) condition improved upon defecation? how severe was his diarrhea? acute chronic intmittent?hx of travel !!! alcohol? fhx! nocturnal diarrhea?(suggests organic disease

DDx diarrhea:
gastroenteritis ac
parasitic infestation( giardia lamblia)
IBS
IBD
CRC
gluten enteropathy
coeliac disease
drugs- antibiotics, laxatives, toxics
malabsorption!!!
autonomic neuropathy!!
SSc
hyperthyroidism!!!!

psst: think of other systems too!

mallory weiss syndrome: tear of the lower end of oesophagus , commonly due to retching.only involves the mucosa and submucosa unlike boerhaave syndrome which is transmural in nature.in this case there is rupture of the oesophagus.there is neuromuscular incoordination. most common site is leftposterolateral part of lower oesophagus. boerhaave synd. is likely to be more severe in presentation- expect shock. however diagnosis can be difficult.

prolonged diarrhea is an indication to perform endoscopy!

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