What's the Diagnosis?

Hanumanthu 45/M
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.

Examination:

• 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

Systems:

ABDOMEN:

• Thin, Liver palpable 2.0 cm
• Spleen NP
• No evidence of free fluid

CNS:

• Gd III/V power both Upper as well as lower limbs
• DTJ: Sluggish
• Plantars: Flexor

CVS/RS: NAD

What's the suspicion?
How will you proceed - remember this is a primary care setting.

PART 2

Investigations:

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

Part 3

The patient comes back after a couple of days:
No change except that the joint pains have reduced:

Investigations:

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???

Answers please

Cases of the Month - June 2006

Naresh, aged 10, presented to us with right sided pain abdomen and


severe respiratory distress. Clinically he was febrile 40 C, tachypnoeic (RR > 45/min), BP 90/60 and falling, Abdomen was tense with guarding in the Rght upper quadrant, Trachea shifted to left with absent movements and breath sounds in the Right Hemithorax. An erect plain film confirmed the clinical findings.
We suspected an Amoebic Liver Abscess which had burst upwards. We stabilised him with IV fluids, IV antibiotics and transferred him immediately to St Johns Medical College, where > 2.7 litres of pus was drained. A pigtailed catheter drained for a week.
He is now better though there is a residue of Right Lower Lobe atelectatsis, which should improve with chest physiotherapy.
Venkataramanama, aged 9 presented to us with progressive loss of weight, anorexia, nausea, early fullness, easy fatiguability and multiple lymph nodes (axillary as well as cervical). Clinically she was febrile 38 C, marked pallor, firm, tender nodes 1.5 x 2 cm size. Her abdominal findings were classical - Doughy abdomen, with dull note on percussion, diminished bowel sounds.
Investigations: Hb 6 gm%, ESR 110 mm 1 st hour, X-Ray showed hilar flare and enlarged para hilar nodes. Weight 12 kg
This was enough to come to a diagnosis of (1) Disemminated TB (2) Grade 3 Malnutrition.
We have started her on Anti Tuberculous Treatment with adjunct steroids, nutritional supplements (basically stuff like jaggery, ragi, fenugreek, spinach, drumstick leaves, sprouts) and am happy to report that she is doing well.
She is now 4 weeks into the treatment and her Hb is 9 gm%, apetite has markedly improved, weight has gone up to 15 kg.
We are hopeful that she will recover well enough in due course.
Watch this space for progress reports.

April - June 2006

Hi all

Am back after a long time.
As promised here is a monthly update on the Health Centre Activities.
We had closed for a much needed vaction from Mid April - Mid May and now we are back in TOP GEAR - cruising along seeing upwards of a 100 patients in the OPD.
We also had a number of unusual as well as interesting cases over the last few weeks. Will be putting these up with pictures in the next couple of days.
Hey guys we are hard up here - ANY HELP????

Kartik