Presented with H/O
- Increasing difficulty in walking: 4 days
- Pain in the joints with associated swelling: 4 days
On further questioning:
- Progressive loss of weight: 4 months
- Anorexia: 4 months
- No h/o - Nausea/Vomiting/Haematemesis/Cough/Fever/Unusual swellings/Non healing ulcers.
- Weight 39 kg Height 170 cm, Afebrile
- Pallor ++, Icterus +/-, Bilateral pitting oedema over the ankles, No lymphadenopathy/ Clubbing/ Skin changes
- Pulse 110/minute, BP 110/70 mm Hg
- Thin, Liver palpable 2.0 cm
- Spleen NP
- No evidence of free fluid
- Gd III/V power both Upper as well as lower limbs
- DTJ: Sluggish
- Plantars: Flexor
What's the suspicion?
How will you proceed - remember this is a primary care setting.
Hb: 9.5 gm%, TC 6000/cumm, P 88 (Neutrophils show toxic granulations) L12, RBS 115 mg%
Urine: Albumin +++, Pus cells Numerous, RBCs 1-2, Epith Cells 2-4, Ca Oxalate crystals 8 - 10
X-Ray Chest PA: Hilar flare ? Para hilar and mediastinal nodes enlarged
The following tests ordered LFT , Blood Urea, Creatinine, HIV and HBSAg
Wow - now what - the picture gets more and more confusing:
So when in doubt - Started Cap Amoxycillin 500 mg tid along with B-complex
The patient comes back after a couple of days:
No change except that the joint pains have reduced:
Total Bilirubin: 2.15 mg%, Direct 1.55, Indirect 0.60 ???
SGOT: 113 u/L, SGPT 24 u/L, Alk PO4ase 134 IU/L
Total Proteins 5.6 gm%, Albumin 3.4, Globulin 2.2, A:G Ratio 1:1.5
Urea 15 mg%, Creatinine 0.9%
HIV (Tridot) -ve HBSAg (Hepacard)-ve
On the basis of this a presumptive diagnosis of CA Head Pancreas was made - on clinical grounds
USG: Hepatomegaly with fatty changes, Large cystic lesion of Head of pancreas (?Infective etiology), Cystic lesion Anterior to Aorta - possibility of necrotic lymph node/Aneurysm
NOW WHAT - Patient has disappeared and we are trying to trace him.
Are we looking at a TB etiology???