History and PE Fiona Javelosa

The Curious Case of John Dick Group 3 Clinical Clerk Batch 2012 SY

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

Chief Complaint Jaundice for 1 month

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

Past Medical History: – Osteoarthritis, right ankle – took unrecalled medication for 1 month – No Hypertension, Diabetes Mellitus, Asthma, Cancer – No history of Hepatitis B or C Family History – Tuberculosis – Mother – No history of Hypertension, Diabetes Mellitus, Asthma, Cancer – No history of hemolytic disorders Social History: – Non-smoker, non-alcoholic beverage drinker

Review of Systems No weakness, sweating, fatigue No changes in hair/nails No visual impairment or double vision No hearing impairment, ear pain, tinnitus No frequent colds/cough, DOB No palpitation, chest pain, edema No history of abdominal trauma, dysphagia No urinary symptoms, polyuria No breast lump, pain or discharge No cyanosis, varicosity No frequent headache, tremors, vertigo No joint stiffness

Physical Examination GeneralAwake, conscious, coherent, not in cardiorespiratory distress Vital SignsBP 90/50 mmHg HR 64 bpm RR 18 cpm T 36.4 deg Celsius 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

Physical Examination AbdomenGlobular, No caput medusae, No bulging flanks, Normoactive bowel sounds, Tympanitic, Soft, Positive direct tenderness over epigastric area, No palpable masses, No hepatosplenomegaly (Liver span = 9cm), No fluid wave, No shifting dullness, Negative Murphy’s sign

Physical Examination ExtremitiesFull and equal pulses, no edema, no cyanosis, Presence of jaundice Mental Status ExamIntact Cranial NervesIntact Motor, Sensory, Cerebellar Intact

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