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GS III SGD

GS III SGD. January 28, 2012 Block 10A. Patient Profile. EC, 49/M from Cavite Married with 2 kids, works as a carpenter Chief complaint: Jaundice. History of Present Illness.

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GS III SGD

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  1. GS III SGD January 28, 2012 Block 10A

  2. Patient Profile • EC, 49/M from Cavite • Married with 2 kids, works as a carpenter • Chief complaint: Jaundice

  3. History of Present Illness 1 month PTA, Pt started experiencing acute onset RUQ pain, VAS 5/10, worsened by activity and eating. (-) nausea, vomiting, fever, jaundice. RUQ pain persisted, no consult done, until… 4 days PTA, persistence of pain and onset of jaundice with tea-colored urine prompted consult at a local Cavite hospital. (-) n/v, fever. UTZ done, A > choledocholithiasis

  4. History of Present Illness HBT UTZ done (Jan 3, 2012): non-visualized gallbladder, could be due to perihepatic/hepatic infection, physiologic contraction, sludge vs stone-filled lumen and small gb; choledoectasia 2 to DBD calculus or mass lesion, pressure effect 2 to inflamed pancreas; prominent hypoechoic pancreas, consider pancreatitis Persistence of sx prompted consult at PGH.

  5. Review of Systems (-) fever (-) headache (-) acholic stools (-) bowel movt changes (-) pruritus (-) DOB, chest pain, palpitations (-) melena, hematochezia

  6. Past Medical History (-) HPN, BA, DM, allergies (-) Hep B (-) previous surgeries/hospitalizations

  7. Personal & Social History • Works as a carpenter • (-) alcohol, smoking, illicit drug use

  8. Physical Examination • Alert, awake, coherent, NICRD • 130/80 90 20 36.3 • Anicteric sclerae, pink conjunctivae • (-)anterior neck mass, CLAD • Equal chest expansion, clear breath sounds • Adynamic precordium, distinct heart sounds, normal rate & regular rhythm, (-) murmurs

  9. Physical Examination • Soft & flabby abdomen, normoactive bowel sounds • (+) guarding, (+) RUQ tenderness on light palpation, (-) palpable masses • Full & equal pulses, pink nailbeds, (-) cyanosis/clubbing/edema

  10. Admitting Impression • Obstructive Jaundice 2 to choledocholithiasis, t/c biliary pancreatitis

  11. Diagnostics WBC 6.10 RBC 4.31 Hgb 134 Hct 0.380 MCV 88.1 MCH 31.0 MCHC 352 RDW 15.4 Plt 268 Neut 0.609 Lymph 0.257 Mono 0.107 Eos 0.025 Baso 0.001

  12. Diagnostics BUN 5.10 Crea 79 Alkphos 516 TB 222.4 DB 124.8 IB 97.6 Amylase 51 Lipase 103 Na 136 K 3.6 Cl 103

  13. Diagnostics Urinalysis: yellow orange, slightly cloudy pH 5.5 sp gr 1.043 Trace blood (+++) bilirubin (+) urobilinogen (-) ketones, nitrites, leuk, aa Trace albumin (+++) glucose FBS 14.68

  14. Diagnostics • PT 16.2/0.87/1.18 • PTT 30.6/28.8 • Albumin 25 • CA 19-9 30.43

  15. Diagnostics • Upper GI Endoscopy: scope inserted up to D2 with difficulty, (+) extrinsic mass at D1, normal stomach, normal LES, normal esophagus. A > t/c pancreatic CA • HBT UTZ:

  16. Plan • For EL with intraoperative ultrasound

  17. Findings at Operation • Pt underwent EL with intraoperative UTZ on January 25, 2012: PeriampullaryCaSt IV with liver metastasis

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