• A 60 year old female Mrs. Soniya, who is a homemaker coming from Ambattur belonging to low socioeconomic class came with chief complaints of yellowish discolouration of eyes for the past 2 months
History of presenting illness:
Patient was apparently normal 2 months back after which she noticed
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Yellowish discolouration of the eyes
- 2 months
- insidious in onset
- intermittent
- not associated with abdominal pain
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H/O itching – 2 months
- insidious in onset
- intermittent
- all over the body
- more over the abdomen
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• h/o passage of high coloured urine – 2 months, intermittent
• h/o passage of clay coloured stools - 2 months,
• Intermittent
• h/o loss of weight & loss of appetite
• h/o fatigue
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No h/o vomiting
• No h/o diarrhoea/ constipation
• No h/o hemetemesis
• No h/o melena
• no h/o abdominal distension
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• no h/o swelling of legs
• no h/o altered sleep pattern
• no h/o dyspepsia
• no h/o ball rolling movements
• No h/o passage of worms in stools
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Past history:
No h/o similar complaints in the past
No h/o previous surgeries
No h/o Diabetes mellitus, hypertension, Asthma, Tuberculosis, Epilepsy
• No h/o chronic drug intake
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• No h/o blood transfusion
• No History of tattooing
• No h/o allergic to foods or drug
Personal history:
She consumes non-vegeterian diet
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Normal bowel & bladder habits
Not a smoker or alcoholic
No iv drug abuse
No h/o pets
Family history:
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No similar complaints in the family
General Examination:
Patient is conscious, oriented, moderately built & nourished.
No pallor
Icterus present
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No cyanosis/clubbing/pedal edema/ Generalized lymphadenopathy
Head to foot examination :
• Yellowish discolouration of Sclera, soft palate, undersurface of the tongue, skin
• scratch marks seen over the abdomen
• No signs of liver cell failure like alopecia, madarosis, palmar erythema, dupuytrens contracture, spidernaevi
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• No flapping tremors
Vital signs:
• Pulse: 74/min, normal- Rhythm, volume, character, no radio-radial/ radio-femoral delay, all peripheral palpable pulses are felt, no vessel wall thickening.
• Blood pressure:120/80mmHg
• Respiratory rate: 14/min
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• Afebrile
Inspection:
After getting consent from the patient & explaining the procedure, patient cloth is stripped from the level of nipple to mid thigh and examined in bright light.
Abdomen is normal in shape
not distended
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umbilicus in mid line
• Flanks free
• All quadrants move equally with respiration
• No scars, sinuses, dilated veins
• No visible pulsations
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• No VGP/VIP
• Hernial orifices are free
• External genitalia normal
• Renal angle – no fullness
• Supraclavicular area – no fullness
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Palpation:
Patient examined with legs semiflexed
• Not warmth, not tender
• A globular swelling of size 4 x 4 cm palpable in the Right hypochondrium which extends 5cm from costal margin & 4 cm from midline
firm in consistensy
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surface - smooth
margins – well defined, upper limit continues with liver
• Moves with respiration
• Moves side to side
• Unable to insunuate finger between the swelling & costal margin
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• Liver is palpable 3 cm below the costal margin, firm in consistency, surface smooth, margins well defined
• Murphy's sign - Negative
• No other palpable mass
• No muscle rigidity & gaurding
• No fluid thrill
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• Renal angle – normal
• Left supraclavicular nodes - no palpable nodes
Percussion:
• Dull note heard over the region of swelling
• Liver dullness starts at right 5th intercostal space in midclavicular line
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• Liver span 17 cm
• No shifting dullness
Auscultation:
Normal bowel sounds heard
no arterial bruit
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no venous hum
Other system examination
• CVS: s1, s2 heard, no murmurs
• RS: normal vescicular breath sounds heard, no added sounds
• CVS: no focal neurological deficit
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• Spine & cranium normal
Diagnosis:
A case of obstructive jaundice probably due to periampullary carcinoma
Investigations:
Baseline investigations:
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Complete hemogram: TC, DC, Hb%, ESR
Blood grouping & typing
BT & CT
Blood – sugar, urea, Serum creatinine
X-ray chest
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ECG
Specific Investigations:
LFT: serum bilirubin (direct & indirect)
Serum proteins, A:G ratio
Prothrombin time
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Liver enzymes – AST, ALT, ALP, GGT
Urine : bile salts, bile pigments, urobilinogen
USG abdomen
CT abdomen
MRCP
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Endoscopic ultrasound
ERCP
PTC if ERCP fails
CA 19-9
CT/MR angiogram or venogram
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Treatment:
Whipple's operation (Radical pancreaticoduodenectomy with triple anaestamosis)
Removal of tumour with head & neck of pancreas, C loop of duodenum, distal stomach, lower end of common bile duct along with removal of peripancreatic, perihepatic, pericholedochal, para duodenal nodes.
• Continuity is maintained by choledochojejunostomy, pancreaticojejunostomy & gastrojejunostomy.
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This download link is referred from the post: MBBS Final Year Case Presentation (Clinical Case Examination, Discussion and Treatment)
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