Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Surgery Final Year Case Presentation Obstructive Jaundice Clinical Examination Discussion and Treatment
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
Yellowish discolouration of the eyes
- 2 months
- insidious in onset
- intermittent
- not associated with abdominal pain
H/O itching ? 2 months
- insidious in onset
- intermittent
- all over the body
-more over the abdomen
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
No h/o vomiting
No h/o diarrhoea/ constipation
No h/o hemetemesis
No h/o melena
no h/o abdominal distension
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
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
No h/o blood transfusion
No History of tattooing
No h/o allergic to foods or drug
Personal history:
She consumes non-vegeterian diet
Normal bowel & bladder habits
Not a smoker or alcoholic
No iv drug abuse
No h/o pets
Family history:
No similar complaints in the family
General Examination:
Patient is conscious, oriented, moderately built &
nourished.
No pallor
Icterus present
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
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
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
umbilicus in mid line
Flanks free
All quadrants move equally with respiration
No scars, sinuses, dilated veins
No visible pulsations
No VGP/VIP
Hernial orifices are free
External genitalia normal
Renal angle ? no fullness
Supraclavicular area ? no fullness
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
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
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
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
Liver span 17 cm
No shifting dullness
Auscultation:
Normal bowel sounds heard
no arterial bruit
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
Spine & cranium normal
Diagnosis:
A case of obstructive jaundice probably due to
periampullary carcinoma
Investigations:
Baseline investigations:
Complete hemogram: TC, DC, Hb%, ESR
Blood grouping & typing
BT & CT
Blood ? sugar, urea, Serum creatinine
X-ray chest
ECG
Specific Investigations:
LFT: serum bilirubin ( direct & indirect )
Serum proteins, A:G ratio
Prothrombin time
Liver enzymes ? AST, ALT, ALP, GGT
Urine : bile salts, bile pigments, urobilinogen
USG abdomen
CT abdomen
MRCP
Endoscopic ultrasound
ERCP
PTC if ERCP fails
CA 19-9
CT/MR angiogram or venogram
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.
This post was last modified on 08 August 2021