The case should be an unusual diagnosis, or a complex case that required in-depth evaluation on the student’s part. The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan. The posting does not have to be written in APA format, but should be written with correct spelling and grammar. References should be in APA format. The selected references should reflect current evidence – dated within the past 5 years.

Case Presentation: A Rare Diagnosis of Primary Biliary Cholangitis

Patient Information:
Name: Mrs. R
Age: 46
Sex: Female

Chief Complaint:
Mrs. R presents with a two-month history of fatigue and pruritus. She reports a gradual onset of symptoms, which have progressively worsened over time. She denies any significant weight loss or night sweats.

History of Present Illness:
The patient states that she first noticed mild pruritus on her extremities about two months ago. She describes the sensation as intense itching, more pronounced at night. Attempts to alleviate the itching with over-the-counter antihistamines provided minimal relief. Over the following weeks, Mrs. R started experiencing generalized fatigue and malaise. She sought medical attention when her symptoms became debilitating, interfering with her daily activities.

Past Medical History:
Mrs. R has a history of hypertension and is on regular medication (amlodipine 5mg daily). She denies any prior surgical interventions or significant medical conditions.

Social History:
The patient has a sedentary lifestyle and works as an office administrator. She denies tobacco or alcohol use. There is no history of intravenous drug use or high-risk sexual behavior. She has been in a monogamous relationship with her husband for 20 years.

Family History:
There is no significant family history of autoimmune diseases, liver disease, or malignancies.

Review of Systems:
Constitutional: The patient reports fatigue, malaise, and unintentional weight loss.
Musculoskeletal: No joint pain or swelling.
Cardiovascular: Denies chest pain or palpitations.
Respiratory: No cough or shortness of breath.
Gastrointestinal: Reports intermittent mild nausea, but no vomiting or changes in bowel habits.
Genitourinary: No dysuria or hematuria.
Neurological: No numbness, tingling, or weakness.
Dermatological: Reports generalized pruritus.

Physical Examination:
Vital signs: Blood pressure 130/80 mmHg, heart rate 76 bpm, respiratory rate 16 breaths per minute, temperature 36.7°C.
General: Well-nourished, non-toxic appearance.
Skin: Mild jaundice observed, with excoriations secondary to scratching.
Cardiovascular: Regular rate and rhythm, no murmurs.
Respiratory: Clear lung sounds bilaterally.
Abdomen: No hepatomegaly or splenomegaly, no tenderness or palpable masses.
Neurological: Oriented to person, place, and time, intact cranial nerves, normal motor and sensory function.

Diagnostic Evaluation:
Laboratory findings:
Complete blood count: Within reference range.
Liver function tests:
– Serum total bilirubin: 2.8 mg/dL (normal range: 0.3-1 mg/dL)
– Alanine aminotransferase (ALT): 60 IU/L (normal range: 5-40 IU/L)
– Aspartate aminotransferase (AST): 50 IU/L (normal range: 5-40 IU/L)
– Alkaline phosphatase (ALP): 350 IU/L (normal range: 30-120 IU/L)
– Gamma-glutamyl transferase (GGT): 250 IU/L (normal range: 10-60 IU/L)
– Albumin: 3.7 g/dL (normal range: 3.5-5 g/dL)
– Prothrombin time: Within reference range.

Serologic testing:
– Anti-mitochondrial antibodies (AMA): Positive.
– Antinuclear antibodies (ANA): Negative.
– Smooth muscle antibodies (SMA): Negative.
– Anti-human liver kidney microsomal antibodies (anti-LKM): Negative.
– Immunoglobulin M (IgM): Elevated (630 mg/dL; normal range: 40-230 mg/dL).

Liver imaging:
Abdominal ultrasound: Normal liver echotexture, no evidence of biliary tract obstruction or intrahepatic masses.

Liver biopsy:
Histopathological examination of liver tissue reveals chronic inflammation and lymphocytic infiltration of the small intrahepatic bile ducts, consistent with the diagnosis of primary biliary cholangitis.

Differential Diagnoses:
1. Primary sclerosing cholangitis
2. Autoimmune hepatitis
3. Drug-induced liver injury

Treatment Plan:
The management of primary biliary cholangitis focuses on slowing disease progression, reducing symptoms, and preventing complications. Mrs. R will be started on ursodeoxycholic acid (UDCA), the mainstay of treatment for primary biliary cholangitis. UDCA has been shown to improve liver biochemistry, delay the need for liver transplantation, and improve long-term survival. The initial dose will be 13-15 mg/kg/day, divided into two daily doses. Follow-up liver function tests will be conducted in three months to assess the response to treatment. Additionally, the patient will receive supportive therapy for symptom relief, including antihistamines for pruritus and vitamin D and calcium supplementation to prevent osteoporosis. Regular monitoring and screening for liver-related complications, such as hepatocellular carcinoma, will also be incorporated into the long-term management plan.

References:
1. Lindor KD, Bowlus CL, Boyer J, Levy C, Mayo M. Primary Biliary Cholangitis: 2018 Practice Guidance from the American Association for the Study of Liver Diseases. Hepatology. 2019;69(1):394-419.
2. Farkkila M, Karvonen AL, Nurmi H, et al. The prevalence and incidence of primary biliary cholangitis in a defined Finnish adult population. Liver Int. 2018;38(4):672-677.
3. Eaton JE, Lindor KD. Primary Biliary Cholangitis: Diagnosis and Treatment. Clin Gastroenterol Hepatol. 2016;14(3):357-368.