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

Identifying Data L.S. 64-year-old Female Roman Catholic Tondo, Manila Intermittent abdominal pain of 6 months

duration and jaundice of 1 month duration

History of Present Illness6 months PTA, patient started to experience cramping epigastric pain with pain score of 3/10 which was relieved by flatus and increase in fluid intake. She had consult and was treated as UTI and dispepsia and was prescribed with unrecalled medications. She was also adviced to avoid coffee intake. Symptoms managed until.

1 month PTA, upon routine check up at Jose Reyes Hospital Rheumatology Department, patient’s physician noted jaundice on the patient. She was adviced to have Ultrasound done. During this time patients abdominal pain increase in PS 5/10, (+) tea-colored urine, (-) acholic stools, (-) fever. Na, K, Crea were also done during this time.

2 weeks PTA, patient had ultrasound which revealed ill-defined structure at the region of the peripancreatic head with secondary dilation of the intra and extrahepatic and pancreatic ducts. These finding are worrisome for periampullary growth. CT/ERCP recommended for confirmation. SGPT, SGOT done.

11 days PTA, patient brought UTZ result at Tondo General Hospital ER. She was admitted and had CT Scan done which revealed dilated intra and extrahepatic ducts, hydrops of the gallbladder, atrophic pancreas. She was confined for 3 days. CBC,Lipid profile, PTT, Bilirubins also done. She was adviced to have ERCP but due to unavailability, patient was discharge and was referred to UERM to have the said procedure at our institution.

4 days PTA, she had ERCP done but failed due to unsuccessful cannulation of common bile duct and papillotome. She was prescribed with Penfloxacin 400mg BID and was adviced to have PTBD.

On the day of admission, due to persistence of symptoms and physicians advice to have PTBD, patient was admitted.

Past Medical History: (-) HTN, DM, asthma, CA

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

SHx: nonsmoker, non-alcoholic beverage drinker

Physical Examination General: Patient awake, alert, not in

cardiorespiratory distress. VS: BP 90/50; HR 64bpm; RR 18bpm; 36.4C HEENT: Icteric Scerae, yellowish palpebral

conjunctivae, no tonsilopharyngeal congestion, no cervical lympadenopathy. Yellowish oral mucosa.

Chest: Equal chest expansion, clear breath sounds

Heart: Adynamic precordium, normal rate regular rhythm, disting S1 and S2, no murmurs

Abdomen: Globular soft abdomen, NABS, (+) tenderness at epigastric area, (-) palpable masses. No hepatomegaly. Liver Span: 9cm.

Extremities: Full equal pulses, no edema, no cyanosis

Mental Status Exam Frontal: Alert, awake, good attention span. Parietal: no right and left disorientation, (-)

finger agnosia, intact gnostic function Temporal: Intact recent, past and remote

memory, oriented to time place and person Occipital: can identify colors and objects

(red, green, and pen)

Cranial Nerves CN I: not assessed CN II: 3-4 mm EBRTL CN III, IV, VI: full EOMs CN V: Intact V1, V2 and V3 on the right CN VII: No facial assymetry CN VIII: intact gross hearing CN IX, X: uvula midline, able to swallow CN XI: able to rotate head, good shoulder shrug CNXII: tongue midline (-)atrophy

Motor strength: 5/5 on all extremetiesSensory: 100% on all modalitiesMeninges: Neck suppleCerebellar: (-)dysmetria, (-)

dysdiadochokinesia (-) Babinski

CBC 8/23HGB 94HCT 26RBCWBC 4.0Neutrophils 61.5Lymphocytes 34.9Eosinophils 3.5Basophils 0Platelets 249

8/23 Ref.

A/G 1.8 1.1-2.2

Dir. Bilirubin

223.7 3.4-13.0

Globulin 19.7 15-34Indir. Bilirubin

95.7 0-18

Tot. bilirubin

319.4 8.5-23.6

Tot. protein

55.85 60-83

Albumin 36.16 35-53

UrinalysisColor Dark YellowTurbidity ClearReaction 7.0Sp. Gr. 1.020Protein Negative Sugar NegativeRBC 0-1/hpfWBC 0-2/hpfCastsBacteriaEpithelial cells

few

8/8 Ref.Na 131.80 135-145K 4.71 3.6-5.5Crea 68.77 45-104

8/16 Reference SGPT 201.90 0-45SGOT 220.20 0-35ALP 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