1. Part 1 Final

2. The Curious Case of John Dick Group 3 Clinical Clerk Batch 2012 SY 2011-2012

3. Objectives To discuss an intriguing case of an elderly woman with abdominal pain To elaborate on the approach to jaundice To discuss the diagnostic approaches to jaundice To present the management of obstructive jaundice and review therapeutic options

4. Identifying Data L.S. 64-year-old Widow Vegetable vendor Tondo, Manila

5. Chief Complaint Generalized jaundice of 1 month duration

6. 6 mos PTA4 wks PTA2 wks PTA4 days PTA1 wk PTAAdmission Colicky Abdominal Pain Temporal Profile Weight loss Jaundice Tea-colored urine Loss of appetite

7. Past Medical History: – Osteoarthritis, right ankle – took unrecalled medication for 1 month – Exposure to Tuberculosis – G 4 P 4 (4004) via NSD without complications – No history of cancer – No history of heart failure or valvular defects – No history of Hepatitis B or C – No hemolytic disorders – No dyslipidemia – No history of blood transfusion – No history of needle prick injury – No history of prolonged or high-dose intake of drugs (e.g. Quinacrine, Rifampicin, etc) – No previous hospitalization, surgery, dental surgery

8. Family History – Tuberculosis – Mother – No history of Cancer – No history of hemolytic disorders Social History: – Non-smoker, non-alcoholic beverage drinker – No IV illicit drug use

9. Review of Systems Weight loss (~50 kg  ~36 kg in 1 month) No weakness No persistent cough, night sweats, hemoptysis, fever No edema, difficulty of breathing, orthopnea No breast lump, pain or discharge No abnormal vaginal bleeding No history of abdominal trauma, changes in bowel movement, nausea and vomiting, fatty food intolerance

10. Physical Examination GeneralAwake, conscious, coherent, not in pain, appears ill- looking Vital SignsBP 90/50 mmHg HR 64 bpm Ht 154 cm RR 18 cpm T 36.4 0 C Wt 36 kg BMI 15.1 kg/m 2 HEENTIcteric sclerae, yellowish palpebral conjunctivae, yellowish oral mucosa, no tonsillopharyngeal congestion, no cervical lymphadenopathies ChestEqual chest expansion, no retractions, clear breath sounds, No spider angioma CVSAdynamic precordium, normal rate, regular rhythm, distinct S1 and S2, no murmurs, concordant apex beat and PMI at 5 th ICS LMCL

11. Physical Examination AbdomenGlobular, No caput medusae, No bulging flanks, Abdominal girth = 29 inches Normoactive bowel sounds, Tympanitic, Soft, Positive direct tenderness over epigastric area, No palpable masses, Liver span = 9cm, Spleen not palpable, No fluid wave, No shifting dullness, Negative Murphy’s sign

12. Physical Examination ExtremitiesFull and equal pulses, no edema, no cyanosis, Generalized jaundice Mental Status ExamOriented to person, place and time. Remote, recent past, immediate memory not impaired. Cranial NervesIntact Motor, Sensory, Cerebellar Intact

13. Pertinent Findings PositiveNegative Weight lossDrug or alcohol use Abdominal enlargementBlood transfusion or donation JaundiceTattoos or IV illicit drugs Tea-colored urineHistory of Hepatitis AnorexiaFamily history of Hemolytic disordes Weight lossChanges in bowel movement Nausea and vomiting Fever Fatty food intolerance History of abdominal trauma

14. Pertinent Findings PositiveNegative Icteric scleraeFluid wave, shifting dullness, bulging flanks JaundiceSpider angioma, caput medusae Globular abdomen, softHepatomegaly Splenomegaly Murphy’s sign

15. Assessment Primary Impression – Obstructive Jaundice secondary to Pancreatic Head Mass Differential Diagnoses: – TB Lymphadenitis – Peribiliary cancer – Choledocholithiasis