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

2. 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

3. History of Present Illness 6 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.

4. 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.

5. 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.

6. 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.

7. 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.

8.  Past Medical History : (-) HTN, DM, asthma, CA  FMHx : (-)HTN, DM, CA, liver disease  SHx : nonsmoker, non-alcoholic beverage drinker

9. Physical Examination  Genera l: 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.

10.  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

11. 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)

12. 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

13. Motor strength : 5/5 on all extremeties Sensory : 100% on all modalities Meninges : Neck supple Cerebellar : (-)dysmetria, (-) dysdiadochokinesia (-) Babinski

14. 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

15. 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.

16. 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

17.  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

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

19. 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

20. 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

21.  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

22. 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

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