1. Mock Grand Rounds Group 3 Clinical Clerk Batch 2012 SY 2011-2012

2. Identifying Data  L.S.  64-year-old  Female  Widower  Roman Catholic  Tondo, Manila

3. Chief Complaint Remittent hypogastric pain x 6 months

4. 6 wks PTA 4 wks PTA 2 wks PTA 4 days PTA 1 wk PTAAdmission Abdominal Pain Jaundice Weight Loss Tea-colored urine Loss of appetite Temporal Profile

5.  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

6. Physical Examination GeneralAwake, conscious, coherent, not in cardiorespiratory distress Vital Signs BP 90/50 mmHg HR 64 bpm RR 18 cpm T 36.4 deg Celsius HEENT Icteric sclerae, yellowish palpebral conjunctivae, yellowish oral mucosa, no tonsillopharyngeal congestion, no cervical lymphadenopathies ChestEqual chest expansion, no retractions, clear breath sounds CVSAdynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs

7. Physical Examination Abdomen Globular, normoactive bowel sounds, soft, (+) direct tenderness over epigastric area (-) palpable masses Liver span = 9cm ExtremitiesFull and equal pulses, no edema, no cyanosis, (+) jaundice Mental Status Exam Intact Cranial NervesIntact Motor, Sensory, Cerebellar Intact

8. Approach to Jaundice

10. CBC8/23 HGB94 HCT26 RBC WBC4.0 Neutrophils61.5 Lymphocytes34.9 Eosinophils3.5 Basophils0 Platelets249 8/23Ref. A/G1.81.1-2.2 Dir. Bilirubin 223.73.4-13.0 Globulin19.715-34 Indir. Bilirubin 95.70-18 Tot. bilirubin 319.48.5-23.6 Tot. protein 55.8560-83 Albumin36.1635-53 Urinalysis ColorDark Yellow TurbidityClear Reaction7.0 Sp. Gr.1.020 ProteinNegative SugarNegative RBC0-1/hpf WBC0-2/hpf Casts Bacteria Epithelial cellsfew 8/8Ref. Na131.80135-145 K4.713.6-5.5 Crea68.7745-104 8/16Reference SGPT201.900-45 SGOT220.200-35 ALP507.4830-120

11. Imaging Abdominal UTZCT ScanERCP 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.

12. 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

13.  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

14. Physical Exam Findings  Icteric sclerae  (+) Jaundice  Globular abdomen, soft  (-) Edema

15. 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

16. 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

17.  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

18. 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

19. Primary Impression  Pancreatic pathology  Pancreatic Head Mass  Biliary tree pathology  Periampullary Mass