الوصف الكامل Background
I saw this case 1 week ago and I am still wroking on it. (not solved yet) I thought it could be a good study case for interested people. Feel free to ask any question, add any comments and try to answer my questions
الشكوى الرئيسية CC
Diarreah and abominal pain for
القصة المرضية HPI
Forty three Y old patient presents with sever vomiting , abdominal pain and diarrhea that has been getting worse for the last few weeks. There is an episodic nature to patients symptoms (episodes of cramps diarrhea and vomiting lasting for 1-3 days), but the episodes are getting more frequent (from one every month or two to once every week and becoming more sever. He describes diarrhea 7-9 times per day : medium to large amount associated with cramps, watery non bloody and awakens him from his sleep. There has not been any clear relationship between food and the diarrhea that seems to be there even if he does not eat. Diarrhea started about 4 years but has increased over the last week weeks to months leading to 10 kg weight loss. As for vomiting it is for old undigested food and it is not as persistent or bothering as the diarrhea. No hematemesis and no dysphagia are present. As for the abdominal pain it is mid abdominal ,described as cramps and decreases after he passes the stool (diarrhea). No aggravating factors ,yet he is afraid of eating . Patient denies heartburn, fever , chills , night sweats ,joint pains or skin rashes.
الأجهزة الأخرى ROS
Review of systems: negative other wise . No cardiac , neurologic, pulomary, hepatic, urinary, skin, or joint symptoms . Just generalized fatigue
السوابق المرضية الشخصية PMH
PMH (past medical history): was diagnosed with HTN years ago but for months has not been taking medications. He was diagnosed with bleeding aneurysm in the brain that was coiled successfully 10 years ago
السوابق المرضية العائلية FMH
PSH : No abdominal surgery
Medications : None for the time being
Family history : He has nine siblings. Two died in car accidents. One sister had a prolonged course of diarrhea and the died after she had surgery and they ?? discovered some type of tumor at age of 47. No other cancer in the family to his knowledge. Father is alive and healthy . Mother died of ? Heart related problems
الوضع الصحي والاجتماعي SH
Social history : No smoking , alcohol or drugs . He is employed in office job. No exposure to chemicals
Allergies : None
الفحص السريري Clinical Exam
BP 85/55 , Temp 37.1 RR 16 Hr 80
General appearance : thin middle aged man ,dehydrated in pain with no respiratory distress
HEENT : No pallor No icterus. Pupils equal round reactive, Extra ocular movements intact. Oral mucosa dry no rashes , throat is clear
Lungs : Clear to auscultation
CVS: S1 S2 normal no murmurs or additional sounds or rubs
Abdomen : Soft , mild periumbilical tenderness no rebound and normal sounds. No hepatoseplenomegaly
Extremities : normal pulses , no edema no clubbing
CNS : Alert ,oriented X 3 with no focal deficits
Initial labs : Na 141 , K 2.3 (very low), Creatinine 0.8, (AST , ALT) normal , Calcium 6.8 ,Albumin 3.1, Magnesium 1.6, CRP 0.2 , Bicarbonate 15.9, Cholride 125, LDH 108, B 12 level 137 (low) , serum folate 20 (slightly high) ,
Random cortisol level 18.5 (done at 10: 45 PM),
WBC 9.4 with 77% neutrophils (slightly up) and otherwise normal differential. Lymphocytic count is 1.2 (low normal) (12.9%). Hemoglobin 15.1 with MCV of 107.8
PT 15.5 (prolonged)
ESR 15 (normal)
Stool analysis : Mucoid with not WBC's or RBC's and negative for ova and parasites
CT scan abdomen reports large paraesophageal hernia. Significantly dilated duodenum , the oral dye goes to the colon (no complete obstruction) . There is osteopenia and compression fracture of L12 vertebral body. The CBD moderately dilated and a question is raised about distal CBD narrowing / compression but no frank mass seen.
Patient gets > 150 meq of K IV, + Linger lactate for rehydration . Surgical evaluation (based on examination recommends no surgical intervention and for medical care
What do you think about the patient diarrhea?
What is the work up you like to obtain?
What do you think about the Dilated CBD?