Mock Grand RoundsGroup 3 Clinical Clerk Batch 2012SY 2011-2012

Identifying Data

L.S. 64-year-old Female Widower Roman Catholic Tondo, Manila

Chief ComplaintRemittent hypogastric pain x 6 months

6 wks PTA

4 wks PTA

2 wks PTA

4 days PTA

1 wk PTA Admission

Abdominal Pain

Jaundice

Weight Loss

Tea-colored urine

Loss of appetite

Temporal Profile

Past Medical History: (+) Osteoarthritis, right ankle – took

unrecalled medication for 1 month (-) HTN, DM, asthma, CA (-) Hepatitis B or C

FMHx: (-)HTN, DM, CA, liver disease

SHx: nonsmoker, non-alcoholic beverage drinker

Physical Examination

General Awake, conscious, coherent, not in cardiorespiratory distress

Vital Signs BP 90/50 mmHg HR 64 bpmRR 18 cpm T 36.4 deg Celsius

HEENT Icteric sclerae, yellowish palpebral conjunctivae, yellowish oral mucosa, no tonsillopharyngeal congestion, no cervical lymphadenopathies

Chest Equal chest expansion, no retractions, clear breath sounds

CVS Adynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs

Physical Examination

Abdomen Globular, normoactive bowel sounds, soft, (+) direct tenderness over epigastric area(-) palpable massesLiver span = 9cm

Extremities Full and equal pulses, no edema, no cyanosis,(+) jaundice

Mental Status Exam

Intact

Cranial Nerves Intact

Motor, Sensory,Cerebellar

Intact

Approach to Jaundice

CBC 8/23

HGB 94

HCT 26

RBC

WBC 4.0

Neutrophils 61.5

Lymphocytes 34.9

Eosinophils 3.5

Basophils 0

Platelets 249

8/23 Ref.

A/G 1.8 1.1-2.2

Dir. Bilirubin

223.7 3.4-13.0

Globulin 19.7 15-34

Indir. Bilirubin

95.7 0-18

Tot. bilirubin

319.4 8.5-23.6

Tot. protein

55.85 60-83

Albumin 36.16 35-53

Urinalysis

Color Dark Yellow

Turbidity Clear

Reaction 7.0

Sp. Gr. 1.020

Protein Negative

Sugar Negative

RBC 0-1/hpf

WBC 0-2/hpf

Casts

Bacteria

Epithelial cells

few

8/8 Ref.

Na 131.80 135-145

K 4.71 3.6-5.5

Crea 68.77 45-104

8/16 Reference

SGPT 201.90 0-45

SGOT 220.20 0-35

ALP 507.48 30-120

ImagingAbdominal UTZ CT Scan ERCP

• Normal sized liver with mild fatty changes•Ill defined hypoechoic structure at the region of the peripancreatic head with secondary dilation of the intra and extrahepatic and pancreatic ducts. These findings worrisome for periampullary growth. CT/ERCP is recommended for confirmation

•Fatty infiltration of the liver•Dilated intra and extrahepatic ducts•Hydrops of the gallbladder•Atrophic pancreas•Atrophic uterus

UGIE•Normal esophagus, stomach and duodenal mucosa

Papilla•Normal-looking with no bile coming out

Pancreatogram•Not done

Cholangiogram•Multiple attempts to cannulate the are of the common bile duct using cannula and papillotome were unsuccessful. Precut using a needle knife was done but still there was a difficulty in cannulating the bile duct.

Pertinent Findings

64/F Intermittent, Progressive Left-sided Pain

over 6 months (3/10 5/10 8/10) (+) Weight loss (+) Abdominal enlargement (+) Jaundice x 1 month PTA (+) Tea-colored urine x 1 month PTA

No particular timing of the day Not associated with food intake No changes in bowel movement No nausea and post-prandial vomiting No fever No fatty food intolerance No pruritus No maintenance medications No altered mental status Non-alcoholic No history of abdominal trauma

Physical Exam Findings

Icteric sclerae (+) Jaundice Globular abdomen, soft (-) Edema

Left-sided Abdominal Pain

Pancreas No vomiting, fever; Not entirely ruled out

Spleen No episodes of acute bleeding or bruises

Descending Colon No changes in bowel movement

Gastric/Duodenal Ulcer Pain not associated with food intake

Jaundice

Drug-Induced No recent or chronic intake of medicines

Carotenoderma Not fond of vegetables

Liver Pathology Non-alcoholic, left-sided pain, no edema, no fever

Gallbladder Pathology No radiation to right shoulder, no fatty food

intolerance, no vomiting, no post-prandial pain, (-) Murphy’s sign

Biliary Tree Pathology No fatty food intolerance; Not entirely ruled out

Pancreatic Pathology Non-alcoholic

Jaundice

Abdominal Enlargement

Liver Pathology (Ascites) Non-alcoholic, Liver span = 9,

Mass (Colorectal Ca, Ovarian Ca, Uterine leiomyoma) No palpable masses; Not entirely ruled out

Obesity (+) weight loss

Hypoalbuminemia

Primary Impression Pancreatic pathology

Pancreatic Head Mass Biliary tree pathology

Periampullary Mass