This is a HIPAA de-identified open-online-patient-record with initial information in patient's voice, posted here early winter 2015 after collecting informed patient consent (form downloadable here ) by LNMCH research assistant and patient-information-communication-executive for a discussion (scroll to the bottom) initiated by patient's primary care physician in-charge:
RECORD MANAGE BY: KULDEEP GUPTA (research assistant and patient-information-communication-executive)
RECORD MANAGE BY: KULDEEP GUPTA (research assistant and patient-information-communication-executive)
Patient ID: PIPER462LONGUM
Patient history:
O/E images:
Doctor's notes:
Investigation images:
new investigation report images 10/12/15:
Clinical conversational decision support:
मोनिका पठानिया राठौर General blood picture, any comments on ivc? Malignancy, kala azar can be possibilities.
Rakesh Biswas Thanks मोनिका, Here's the blood picture:http://1.bp.blogspot.com/.../kyU5-w33p80/s1600/DSCN0472.JPG
Rakesh Biswas Here's the USG which shows a dilated portal vein:http://3.bp.blogspot.com/.../0f3iw8Ty-NE/s1600/DSCN0479.JPG
Rakesh Biswas Looks like 'cirrhosis with large liver.' Will try to get his liver biopsy done tomorrow. Any particular points to look for in liver biopsy particularly for the potential differentials of 'cirrhosis with large liver.'
Yashdeep Das Rakesh Biswas sir, can this be a case of portal hypertension but, there are no mention of anorectal varices or oesophageal varices
Yashdeep Das Rakesh Biswas sir, this is just a guess and a long shot.....but Lupus is also possible.
Rakesh Biswas Thanks Yashdeep for taking this shot as this should also benefit those who are learning in the audience. smile emoticon
Rakesh Biswas Please search for Lupus criteria and let us know how many common criteria this patient may fit into. Let us see if he fits into at least 4 out of the 12 common criteria. Do let us know.
Yashdeep Das The patient has problem in liver, spleen and also kidneys as investigation shows albuminuria and increased serum urea..... Lupus attacks all the above mentioned organs. Rakesh Biswas sir..
Yashdeep Das portal hypertension can be due to the liver cirrhosis which can also occur due to autoimmune hepatitis
Rakesh Biswas Yashdeep there are many other causes of Leucopenia. Can you see if this patient has any of them? Can a large spleen also cause leucopenia Trisha?
Trisha Rana Definitely, an enlarged spleen can be responsible for leucopenia keeping in mind the other causes as well.The detailed answer of your question is as follows:
The effects on your spleen may be only temporary, depending on how well your treatment works. ...See More
The effects on your spleen may be only temporary, depending on how well your treatment works. ...See More
Trisha Rana Among the many causes of leucopenia Bone marrow diseases, bone marrow damage or suppression are very prevalent. In these conditions the bone marrow does not produce sufficient WBCs or selectively produces excess of one type of WBCs leading to a lack of other types. The causes include myelodysplastic syndrome, leukemia, myeloproliferative syndrome, myelofibrosis (bone marrow replaced by fibrous tissues)
Rakesh Biswas Thanks Trisha, So the first part of your answer was perhaps taken from here (or a similar site):http://www.mayoclinic.org/.../basics/causes/con-20029324
Rakesh Biswas It would be a good idea to always share the link from where your information content is taken?
Trisha Rana We can opt for checking levels of vitamin B12 and folate deficiency as it also plays a key role in leucocyte count maintenance.
Rakesh Biswas Also when you share a large amount of content your actual answer tends to get drowned in that? smile emoticon For example in response to the question "Can a large spleen also cause leucopenia?" it would have been easier to have just said yes and quoted a journal article where a possible mechanism to large spleen causing leucopenia may have been studied and described. Please do continue to share your thoughts and queries. smile emoticon
Rakesh Biswas Trisha, Yashdeep, I guess some of you needed to be showed how to palpate his organs as Prof Seema was telling me today that some of you were palpating it from outside his clothes. She will discuss this case in detail tomorrow but meanwhile and even after please feel free to share your thoughts here on what you have gathered till now from your offline interaction with this patient in the wards.
Bhavik Shah Having gone through only a limited amount of information through the thread present here, how about primary myelofibrosis? The history says that the patient has been feeling weak for quite some time. His counts are low. Hepatosplenomegaly with symptoms...See More
Rakesh Biswas Thanks Bhavik, Now we shall need to decide as to which one to go for first. Bone marrow biopsy or liver biopsy. smile emoticon Dr Chandra Mouliany comments?
Chandra Mouli CBC n bloodfilm would be helpful to narrow down the differentials. Tear drop poikilocytes n platelet dysmorphology will be prominent of he has MF. Especially if we are thinking of MF given the duration of the complaints n spleen size. Hepatomegaly is usually not that prominent in MF unless splenectomy had been performed. As BM biopsy is easier may be go for it first.
Rakesh Biswas Dr Ajay, Can you ask any faculty of pathology there in AIIMS if they would be able to perform his bone marrow biopsy? Getting a bone-marrow biopsy needle in Bhopal can be very difficult. Most of the needles here are sternal puncture needles and one can only do aspiration with those. Dr Ratan would you be able to do it?
Rakesh Biswas Prof Seema, Talked to Dr Rajneesh, HOD, AIIMS, Bhopal today and they can do the bone marrow biopsy (they have the needle). I shall send him the details of this patient on email.
Rakesh Biswas Dr Chandra Mouli, Here's his peripheral smear report:http://3.bp.blogspot.com/.../bHMAJrkZYbE/s1600/DSCN0802.JPG
Bhavik Shah Can they provide the microscopic picture of the slide? This much of information seems inadequate I think!
Rakesh Biswas Unfortunately all peripheral smear slides are discarded immediately after reporting as a rule here (perhaps in all places in Bhopal? DrIshan?). I wonder if the same happens in BJMC? smile emoticon
Rakesh Biswas To capture these images even as they are reported we need interns like you here. smile emoticon
Bhavik Shah Umm, I don't know if they discard the slides here or not, but reporting is always in depth for PS like tear cells, parasites, entire morphology of blood cells is covered in reporting. So, at least that makes it a bit easier.
Rakesh Biswas His CT abdomen shows hypodense areas in the spleen suggestive of venous infarcts:http://4.bp.blogspot.com/.../xeDkhohSxIg/s1600/DSCN0804.JPG
Rakesh Biswas We deferred his bone marrow biopsy as his current CBC is suggestive of near normal WBC and platelet counts. The offline consensus in the unit weighs in heavily in favor of cirrhosis or Non cirrhotic portal fibrosis. Perhaps we can just tackle his spleen and reduce its size using a radiological intervention that Dr Agamya does here routinely and perhaps he can also help to get a intra-portal biopsy?
General blood picture? Any Comment on ivc? Malignancy, kale agar need to be ruled out
ReplyDeleteThis comment has been removed by the author.
ReplyDeleteKala azar
ReplyDelete