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A 45 year old welder presented with reduced epigastrium, non tender gall bladder was
urinary output for 3 days. He had a good palpable, No ascites, No loin tenderness.
urinary output in the past and gradually
Hb 12.6, Platlet count 180000, WBC 15270,
reduced urinary output over three days with
n 12690. Albumin +, Red cells 10-15, Pus
dark colored urine. It was associated with
cells 2-3,No casts, no sediments. 74 u/l, 50
pruritus, on and off fever with chills and
u/l (22-60). Glucose 15.4 mmol/l. ALT 108,
rigors. He also had epigastric pain for 5
AST 95, ALP 509, GGT 256, Total protein
days duration. Relevant negative findings
5.4, Albumin 3.3, Globulin 2.1, Total
were, no recent history of diarrhea or
Billurubin 141 umol/l, direct 111. Serum
vomiting, trauma or surgery but nausea is
sodium 135, potassium 4.5, chloride 138.
present but no dysuria, frequency, hematuria
His serum creatinine 3.4 then rose to 5.1.
or loin to groin pains or history of renal
USS abdomen, Evidence of CBD dialatation
stones. No recent hemorrhage or burns and
(1.69cm) and intrahepatic duct dialatation ,
no recent polyuric episodes. No history of
Evidence of hyperechoic area seen in the
periorbital swellings or frothy urine. Patient
head of pancreas, minimal free fluid seen in
has not taken antibiotics, analgesics,
Morrison’s pouch, Bilateral kidneys are
diuretics or drugs for joint pains rather than
swollen and more hypoechoic than normal,
Metformin for diabetes for 5 years. No
and B/L acute renal parenchymal disease.
history of muscle trauma or epilepsy. No
ESR 63, CRP 69. Blood picture no evidence
history of blood disorders. No hiccups or
of hemolysis.
mental state changes. Had treated at hospital
for two episodes of epigastric pains needing
more than three days admission where he
was kept on liquid diets and intravenous Lessons learnt
drugs. Blood sugars were not more than Bile cast nephropathy was diagnosed and
200mg/dl. Non smoker, but consume sent for surgical intervention with
alcohol for 10 years, ½ a bottle arrack a day Endoscopic Retrograde Cholangio
for last three years. Pancreatography for bile duct obstruction as
He was febrile and deeply icteric, not pale, the acute problem. From here onwards when
mild hepatomegaly and splenomegaly and a patient with obstructive jaundice patient
had non-tender palpable gall bladder, no loin comes with renal impairment, will consider
tenderness. Temperature 99 F, No clubbing, Bile cast uropathy as a main differential
not cyanosed, No lymphadenopathy , Blood diagnosis.
pressure 120/80mmHg, Pulse rate –
104/min, regular, JVP- normal, Heart sounds
– normal, No added sounds
(Muffled),Respiratory rate 16/min,
Vesicular breathing , no added sounds, No
effsusions , Abdomen Examination, Tender

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