Case presentation

Dr. Vaibhav Wavhal

JRII,Shalya.

Case Note

• Name- Sheela Devi• Sex- Female• Age-27years• Marital status-married• Address- village in Bihar • Occupation- housewife

Present complaints

1. Pain in right side of upper abdomen >1month

2. Loss of appetite >15days

3. Intermittent fever >15days

4. Vomiting associated with pain >1month

5. Itching sensation >15 days

6. Yellowish discolouration of urine >15days

History of illness

• According to patient, she was asymptomatic 1 month back. Since then she gradually developed pain in right hypochondric region which was not migratory in nature.

• At the same time, she also had loss of appetite which was occasionally associated with vomiting.

• At the time when pain is severe in nature pain spreads over right side of upper abdomen & having intermittent fever.

History of illness

• Since she was not having relief with treatment by local doctors, she came in BHU for better management.

Past history

• Illness-• No any history of Diabetes, hypertension• No H/O BA

• Operation-• No any operative history

• Allergies• No any past history of drug or any environmental allergy

Family history

• No family history relating any major operative procedure preformed

• No any major familial disease history

Personal history

• Diet - mixed

• Bowel- regular with clay colour and normal consistency

• Appetite- decreased

• Addiction- no

Personal history….

• Sleep- normal

• Micturition- 4-6times/day, no burning micturition & with yellowish discolouration

• Menstrual history- regular menses

Physical examination

• GC- average• Fatigue- mild present• Temperature-afebile• Pulse-76/min• BP-106/70mm of Hg• RR-14/min• Icterus present- +++• No pallor, clubbing, cyanosis• Lymph nodes not palpable

Systemic examination

• CNS-

– Patient well conscious– Patient well oriented to time, place & person– No H/O headache, drowsiness, Giddiness,

Syncope, convulsion

Systemic examination…..

• CVS• S1, S2heard normal• No any cardiac murmur• No h/o Chest pain, Palpitation• No Ankle oedema

Systemic examination………

• RS-• Trachea centrally placed• B\L equal chest expansion• B\L equal air entry• Normal vesicular sound heard• No added sound heard

Systemic examination…….

• Gastrointestinal- – Umbilicus centrally placed– No abdominal distension– No visible veins or scar– Bowel sound normal– Per abdomen-

» Soft» Tenderness present at right hypochondric region» Mild hepatomegaly» No splenomegaly

Local examination

• On inspection(nü¶ÉÇxÉ)-– No swelling in any hernial orifice– Skin- normal in colour– Contour-normal, no any distension– Respiratory movt-thoracoabdominal– No visible peristalsis – No any pulsatile swelling

Local examination……

• On palpation(º{ɶÉÇxÉ)-– No any Hyperaesthesia present over sherren

triangle– boas`s sign negative– Tenderness- mild tenderness present at right

hypochondric region– No rebound tenderness– No lump or muscular rigidity

Local examination…..

• On percussion-– No shifting dullness– No fluid thrill– No obliteration of liver dullness

Local….

• On auscultation-– Bowel sound normal

• Per rectal examination-– No any specific findings

– Per vaginal examination- no any specific findings

Provisional diagnosis

• Obstructive jaundice• Clay coloured stool• Yellowish discolouration of sclera , mucus

membrane• Yellowish discolouration of urine• Mild itching

Differential diagnosis

• Choledocholithiasis-• Charcoat`s triad – jaundice, fever, pain

• Stone in pancreatic duct• Jaundice absent

Differential diagnosis

• Cholangitis-• High grade fever with chills and rigors

• Stenosis of sphincter of oddi

• Choledochal cyst

Differential diagnosis

• CA bile duct-

• Peri-ampullary CA• Weight loss• Progressive jaundice

• CA head of pancrease• Painless progressive jaundice with palpable GB• Projectile vomiting followed by severe pain• No any discolouration on loin and umbilicus

Differential diagnosis…..

• Ova cyst & worms of ascariasis

• Lymph node porta hepatis obstructing the biliary tree

Investigations

• Blood investigations• Hb- 10gm%• WBC-11000/cubic mm• P-66, L-24, E-04, M-06• FBS- 78.9mg/dl• Bilurubin- total-6.91mg/dl• Bilurubin-direct-5.62mg/dl• PT—test-13.2sec• PT-control-13.6

Investigations…..

• Sr. Creatinine- 0.7mg/dl• BU- 17.9mg/dl • Sr. Na-136mmol/L• Sr. K- 4.3mmol/L• Sr. Cl-104.0mmol/L• HIV-NR• HBsAg- Negative

Investigations…..

• Any special investigations• USG-cholelithiasis with choledocholithiasis

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