mock grand rounds group 3 clinical clerk batch 2012 sy 2011-2012
TRANSCRIPT
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