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on Feb 16, 2012 Says :
Good case study
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Slide 1 :
Welcome all to Case Presentation
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A young boy with upper abdominal pain & ascites Presenter: Dr. Md. Khalilur Rahman Student of M.D.(Internal Medicine) S.O.M.C.
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Profile of the Patient Abdus Sattar AGE: 14 years Only issue of his parents Home town: Hobiganj
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Chief complaints Upper abdominal Pain for 4 months Abdomial swelling for same duration
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H/O Present illness The patient was alright 4 months back; since then he noticed pain in the upper abdomen, spasmodic in nature, had radiation to back and usually aggravated on taking food with some relief on bending forward. The intensity of pain was severe in last couple of months.
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Contd… He also noticed gradual swelling of the abdomen. The abdominal pain and swelling made him cripple to do his daily activities. He denied nausea, vomiting, low grade evening rise of temperatue, anorexia & weight loss in current course of his illness.He got no alteration of his bowel habit. He had no history of jaundice, hematemesis & melena and tranfusion of blood.
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Contd.. He was admitted twice in hospital & in first visit there was no specific diagnosis at the end. In his second visit he was discharged with the diagnosis of Intestinal TB with chronic calculus pancreatitis. Accordingly anti-TB drugs were started with no improvement of pain and swelling in spite of taking for at least two weeks. Then, he was readmitted for further evaluation.
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Past Medical History An unexplained surgical procedure was done six years back for abdominal complaints.
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Immunization history Not immunized.
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Family history The Parents are alive and in good health. Low socio-economic status.
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Personal history He denied any sort of engagement in activities which are risky and or abusive for health.
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General Examination Appearance: looking ill Body built: below average Nutritional status: below average Anemia: mild Jaundice: absent Cyanosis: absent Edema: absent Dehydration: absent
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Contd… Clubbing: absent Koilonychia: absent Lymph Nodes: Not Palpable Thyroid gland: Normal Pulse: 70 beats/min. Blood Pressure: 100/60 mm Hg JVP: Not raised
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P/A EXAMINATION Inspection: Umbilicus-everted, Flank- full. No visible peristalsis, engorged vessels and pulsations. No pigmentation. Scar mark- in the midline. Hernial orifices: intact. .
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Palpation: On superficial and deep palpation there was definite tenderness in the epigastric region. No organomegaly was found. Para aortic lymh nodes: Not palpable. Testes: Normal
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Contd… Percussion: Shifting dullness was positive. Upper border of the Liver dullness in the right 5th inter costal space. Auscultation: Bowel sound- normal; No audible Bruit; Succusion splash- Negative
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Slit lamp examination for K-F ring : Negative. Examination of other systems revealed normal
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Salient feature Abdus Sattar, a teenage boy admitted for third time in Sylhet MAG Osmani Medical College Hospital with upper abdominal pain and ascites for 4 months. The pain was severe, spasmodic in nature, aggravated on taking meals and relieved on bending forward.He had no associated anorexia, nausea, vomiting, altered bowel habit with absence of fever and weight loss.
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Contd.. There was absence of clinical stigmata of Chronic Liver disease with Slit lamp examination for K-F ring found negative. There was no clinical improvement with anti-TB drugs started for 2 weeks. On examination he was mildly anemic & Ascites was revealed. There was no organomegaly but presence of tenderness in the epigastric region. All other systems were found normal.
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Provisional diagnosis Chronic calculous Pancreatitis with Ascites due to ?
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Differential Diagnosis Tubercular Peritonitis. C.L.D.
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Investigations Previous records: 1.Radiological and sonological evidence of Pancreatic calculus. 2. Exudative Ascites: 5.8 gm/dl with lymphocyte predominant cytology. 3. Tuberculin test: 20 mm 4. E. S. R. : 50 mm in 1st hr.
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Contd… Current Records: Complete Blood count normal with E.S.R. 45 mm in 1st hr. Urine R/E: Normal. Chest X-ray P/A view: Normal. USG of the W/A: Pancreatic Pseudocyst S. Amylase:400 U/L ; RBS: 90 gm/dl L FTs including Viral markers(HBsAg & anti HCV): Normal .
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Contd.. Ascitic fluid study: Tea colored; Exudative : 3.7gm/dl ; Cytology: Co-dominated by neutrophil and lymphocytes. Ascitic fluid ADA level:12.7IU/L Amylase level in Ascitic fluid: 21,818U/L
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Contd… Upper GI Endoscopy: Normal CT scan of Upper abdomen: Pancreatic Pseudocyst
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Final diagnosis Chronic Pancreatitis with Pseudocyst and Pancreatic ascites.
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Reassessment of the patient The Patient was managed conservatively with almost negligible improvement of pain & ascites. So, in view of reassessment a surgical opinion was sought and later shifted to surgery ward for further management.
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Surgical intervention The surgical team fixed a date and the patient was managed with a specialized Percutaneous drainage of Pseudocyst. In course of time the patient started to get relief and at least 15 L tea color fluid came out till the drain was off.
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Smile in the face of the patient at the end….. On repeat Sonology there was no evidence of Pseudocyst. He neither mentioned any abdominal pain nor there was ascites for the last seven days and then planned for discharge & further follow-up.
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A young boy presented with upper abdominal pain and Ascites
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