Case Protocol A Case of Insulinoma

1. Case ProtocolA Case of Insulinoma FontanoMJ, Francisco TP, Gabuat H, Gaffud PB, Gagtan M, Gallardo ELH, Garan EA, Garcia KFL, Garcia MJ, Garzon MMP, TolentinoMK June 9, 2010

2. General Data • JR • 50 y/o F • Married • Filipino • Born Again Christian • Imus, Cavite • Unemployed • DOA: April 14, 2010

3. Chief Complaint • Generalized weakness

4. History of Present Illness

5. History of Present Illness

6. Review of Systems • (+) gain weight approximately 50% after 2 years • No other signs and symptoms of insulinoma noted ie: • Abdominal pain • Anxiety • Black tarry stool • Bloatedness • Burning/aching/hunger discomfort in the upper abdomen or lower chest that is relieved by antacids/mlk/food • Decrease libido • Headache • Amenorrhea • Infertility • Anorexia • Loss of coordination • Sensitivity to cold

7. Past Medical History • (+) acute renal failure s/p hemodialysis (3 sessions) - 2005 • (+) CAP (2005 • (-) hypertension • Not known diabetic • No asthma, allergies, thyroid disease

8. Family History • (+) hypertension –father • (+) stroke – father • (+) asthma – siblings • (+) liver disease – mother • (-) DM • (-) CA (-) allergy (-) kidney diasease

9. Personal and Social History • Non-smoker, non-alcoholic beverage drinker • Usual diet were rice with ice cream and softdrinks • No illicit drug use

10. Mentrual History • M - 14 years old • I – 28-35 days • D – 2 days • A – 3 pads full fully soaked • S – dysmenorrhea: 2

11. Physical Examination • Conscious, coherent, ambulatory, not in cardiorespiratory distress • VS: BP: 120/70 PR: 80 bpm, regular RR: 18 cpm, regular T: 36.200C • Wt: 88.5 Kg Ht: 156cm BMI: 36.4 • Warm, moist skin, (-) active dermatoses, (-) jaundice • Pink palpebral conjunctivae, anictericsclerae • Supple neck, no palpable cervical lymphadenopathy, thyroid not enlarged

12. Physical Examination • Symmetrical chest expansion, (-) retractions, clear and equal breath sounds • Adynamicprecordium, AB at 6th LICS AAL, S1>S2 apex, S2>S1 base, (-) murmurs • Globular abdomen, NABS, soft, liver span 8cm R MCL no palpable mass, Traube’s space not obliterated, no tenderness, no mass palpated, (-) Murphy’s sign, (-) CVA Tenderness • Pulses full and equal, no cyanosis, no edema

13. Neurologic Exam • Neurologic Exam: • MSE: Conscious, coherent, oriented to person, place and time, can follow simple and complex commands • Cranial Nerves intact • Pupils 2-3 mm ERTL, EOMS full and equal, • V1V2V3 intact

14. Neurologic Exam • No facial asymmetry, can smile, puff cheeks, raise eyebrows, shrug shoulders, turn head against resistance, tongue in midline • no dysphagia

15. Physical Examination on Admission (04/14/10) • Motor:  • Sensory: intact • Reflexes: DTR (++) on both UE and LE • (-) Babinski

16. Salient Features • 50 yo/F/Married • (+) dizziness, altered sensorium, generalized weakness, sweating • (+) easy fatigability, nausea • (+) blurring of vision • Hypoglycemia • Symptoms relieved by food • Multiple cholelithiasis with fatty liver • (-) sensory deficit • (-) heat/cold intolerance, polyuria, polyphagia, polydipsia

17. Assessment • Hypoglycemia secondary to hyperinsulinemia t/c Insulinoma

18. Plans Diagnostic • CBC with platelet • Urinalysis • Chest Xray • 12 L ECG • TPAG • PT, aPTT Therapeutic • Pancreatectomy

19. 1st hospital Day

20. 12L ECG (4/14/2010) • Sinus rhythm • Sr @ 75/min • Normal tracing

21. Chest Xray (4/14/2010) • Lungfields are clear • Diaphragm and sinuses are normal • The heart is enlarged • Cardiomegaly

24. CBC

25. CBC

26. Urinalysis (4/14/2010)

27. CBG monitoring (mg/dL)

28. 7th hospital day Distal pancreatectomy-spleen sparing procedure

29. Intraoperatively • Induction of General Anesthesia • Asepsis and antisepsis

36. Operative Findings • Mass in the body of the pancreas measuring 2.5cmx2cm

37. Post-Op

39. Chest X-ray (4/20/2010) • R sided CVP line is seen with its tip oriented cephalad • Probable cardiomegaly

41. Thank you!

43. CT Scan