Obstructive Jaundice (Prototype case).pptx

Obstructive jaundice case presentation

1. SURGERY CASE PRESENTATION BY Kousalya N FINAL YEAR, COIMBATORE MEDICAL COLLEGE Under the guidance of Dr. Srinivasan sir

2. PERSONAL DETAILS Name : Mrs. XXX Age : 57 Sex: Female Occupation: Homemaker Residence : YYY

3. CHIEF COMPLAINTS Yellowish discoloration of eyes for past 6 months. Itching all over body for past 6 months. Yellowish discoloration of urine for past 6 months

4. PRESENTING ILLNESS Patient was apparently normal before 6 months , after which she noticed yellowish discoloration of eyes , which was insidious in onset, gradually progressive in intensity, not associated with pain H/O yellowish discoloration of urine , insidious in onset, present for past 6 months. H/O of itching all over the body for past 6 months, causing disturbed sleep. H/O loss of appetite for past 6 months. H/O loss of weight for past 6 months.

5. H/O clay coloured stools for past 6 months. No H/O abdominal pain. No H/O abdominal distension. No H/O passage of black tarry stools. No H/O vomiting blood.

6. No H/O nausea and vomiting.
No H/O fever.
No H/O chronic cough, breathlessness
No H/O headache, seizures, dizziness.

7. PAST HISTORY Recently diagnosed case of Diabetes mellitus 3 months back, on regular medication. No H/O hypertension, Tuberculosis , asthma, COPD, cardiovascular diseases or tuberculosis. No H/O similar illness in past. No H/O previous surgeries in past. No H/O previous blood transfusion. No H/O any drug intake.

8. PERSONAL HISTORY Consumes vegetarian and non vegetarian diet. No addictive habits. Disturbed sleep due to itching. Normal bladder and bowel habits.

9. MENSTRUAL AND OBSTETRIC HISTORY Perimenopausal lady , last menstruation 7 months back. Previously regular 5/30 days cycle P2, L2 , full term vaginal delivery.

10. FAMILY HISTORY No other member in family has similar complaints.

11. GENERAL EXAMINATION . After attaining consent , under adequate daylight, patient was examined. Patient was conscious, oriented, moderately built. Afebrile, icteric, no pallor, no cyanosis, no clubbing, no bilateral pitting pedal edema, no generalized lymphadenopathy. No signs of liver cell failure seen.

12. VITALS BP – 130/80 mm hg.
Pulse rate – 74 beats per minute.
Respiratory rate – 15 breaths / min.
Temperature – 98.4

13. PER ABDOMEN EXAMINATION Under adequate daylight and privacy, exposing the patient from nipple to mid thigh, local examination was carried out. INSPECTION: Abdomen is flat with umbilicus in midline. Abdomen not distended, flanks are free. A globular mass is seen in right hypochondrium and
right lumbar region – moves with respiration. All quadrants move equally with respiration. Scratch marks seen on skin over abdomen.

14. No visible pulsation.
No visible peristalsis.
No dilated veins.
No fullness in left supraclavicular fossa.
Hernial orifice free.
External genitalia normal.
No renal angle fullness.

15. PALPATION No localized warmth or tenderness. A 7x5 cm globular shaped mass is palpable in right hypochondrium & right lumbar region . Medially extending just lateral to lateral border of right rectus abdominus muscle around 7 cm from the midline. Inferior border is 9 cm from the right costal margin . Mass has smooth surface , firm in consistency, moves with respiration.

16. No other mass palpable in abdomen.
No palpable lymph node in left supraclavicular fossa.
Liver span is 12 cm at midclavicular line. No shifting dullness. No fluid thrill

17. PERCUSSION : Dull note on percussion over mass. AUSCULTATION : Normal bowel sounds heard. PER RECTAL EXAMINATION:- not done PER VAGINAL EXAMINATION : not done

18. OTHER SYSTEM EXAMINATION: CVS – s1, s2 heard, no murmurs.
RS- normal vesicular breath sounds, no added sounds.
CNS – no focal neurological deficit.

19. DIAGNOSIS A case of obstructive jaundice probably due to head of pancreas carcinoma.

20. THANK YOU