CPC

MEDICINE DEPARTMENT
12.07.19

Presented by:
Dr. Sajid
Dr. Shumyle
 A 45 YEAR FEMALE WITH
ABDOMINAL DISTENTION, FEVER &
WEIGHT LOSS
FOR 1 MONTH
Presenting Complaints:
1. Abdominal Distention
2. Fever 1 month
3. Weight Loss
HOPI:
Normotensive, Nondiabetic
■ ABDOMINAL DISTENTION:

• Gradual
• Progressive
• Mild to Marked
• Pain
• Restlessness
HOPI:
■ Fever:
• 1 month
• Gradual
• low grade
• without rigors and chills
• evening rise
• documented at 99F
• No night sweats
HOPI:
■ Weight Loss:
• Significant, unintentional
• 5 Kg
• Decreased intake
• Anorexia
• Nausea
• Generalized Weakness
• Heat intolerance, tremors
SYSTEMIC REVIEW:
■ CNS: Headache, Dizziness +ve
No LOC, No convulsions, normal sight & hearing

■ CVS: Palpitations +ve

No orthopnoea, chest pain, paroxysmal nocturnal dyspnoea,
pedal oedema or exertional dyspnoea

■ RES: NO cough, chest pain, sputum, tachypnoea or anosmia

■ Uro: NO burning micturition, urgency, frequency, hesitancy, retention,

haematuria or flank pain

■ MUSCULOSKELETAL: NO Joint pain, swelling or stiffness, No limitation

In movement, No muscle or bone deformity
Past History:

 Past Medical History:

There is no Hx of HTN, DM, Asthma, TB

 Past Surgical History:

There is no significant surgical history present
Family History:
Mother was Hypertensive, Father died 5 years
back due to HCV complications
 Personal History:

• 5 healthy children through SVDs without complications,

Tubal Ligation done 14 years back
• Sleep normal
• Appetite is Decreased
• No Smoking or Alcohol Consumption
• Altered Bowel Habits predominately diarrhoea
Differential Diagnosis:

1. Abdominal tuberculosis
2. Abdominal malignancy
3. Abdominal lymphoma
GPE:
 A middle aged female Pt comfortably
lying on bed, fully conscious and
oriented, ill looking and cachexic

 Jaundice +ve
 Clubbing -ve
 Leukonychia -ve
 Koilonychia -ve
 Oedema -ve
 Thyroid -ve
 Lymphadenopathy -ve
 GIT:
■ Abdomen distended
■ Umbilicus everted
■ Mild tenderness in Rt hypochondrium
■ Liver enlarged total span 18cm,
hard in consistency, nodular ,
irregular margin and tender
■ Moderate ascites
■ Shifting Dullness, Fluid Thrill +ve
■ Tender Splenomegaly 14cm
RESPIRATORY,CVS,CNS,
MUSCULOSKELTAL
■ UNREMARKABLE
 Investigations:
BLOOD CP:
TLC 16.4
NEU 47.5
LYM 48.6
HGB 8.4
MCV 82.9
PLT 116
COAGULATION PROFILE:
PT 33.2 sec
APTT 43.5 sec
INR 3.72
SERUM PROFILE:
ALT 38 U/I
ALP 264 U/I
T.BILIRUBIN 0.6 mg/dl
UREA 13 mg/dl
CREAT 0.6 mg/dl
BSR 126 mg/dl
AMYLASE 56 U/I
ELECTROLYTES:
SODIUM 136 mmol/L
POTASSIUM 3.7 mmol/L
CHLORIDE 99 mmol/L
Investigations:
■ USG Abdomen:
• A large hepatic mass in the left lobe of liver,10cm x
8cm with vascularity on doppler imaging.
• Multiple enlarged lymph nodes measuring 14cm *
10cm lobulated and matted with each other in upper
abdomen.
• Mild to Moderate Ascites
Tumour Marker:
Alpha fetoprotein 126 IU/ml
(<14.4 IU/ml)
CT Triphasic Abdomen Pelvis
with Contrast:
Aggressive looking mass lesion in Lt lobe of liver with
associated lymphadenopathy
■ Anti HCV antibodies negative
■ AntiHBsAg negative

■ Chest X-ray PA view normal

■ Serum Ferritin levels normal
■ Serum ceruloplasmin level normal

■ Serum antitrypsin level normal

■ Serum CA125 normal

Liver Biopsy:

■ Fibrolamellar Hepatocellular Carcinoma

 Final Diagnosis:

■ PRIMARY HEPATOCELLULAR CARCINOMA

Treatment:
 SUPPORATIVE MANAGEMENT

■ Blood transfusion
■ Analgesics
■ Diuretics
■ Proton pump inhibitors
■ Prokinetic agents
■ Laxative
■ Branched Amino acids
Drug of Choice:

■ SORAFENIB 200mg 1x BID