SEMINAR PRESENTATION SGY-1-2. .pptx

medicine

1. EDEN UNIVERSITY SCHOOL OF MEDICINE KANYAMA GENERAL HOSPITAL

2. HISTORY NAME : P C AGE/SEX : 45/F ADDRESS : LUSAKA WEST MARITAL STATUS :MARRIED RELIGION : SDA TRIBE : BEMBA INFORMANT: PATIENT D.O.A : 20/01/25 D.O.C :24/01/25

3. PRESENTING COMPLAINTS Fever x 1/52 Abdominal pain x 1/52 Yellowing of eyes x 5/7

4. HISTORY OF PRESENTING COMPLAINTS Fever 1 week ago noticed fever The fever was acute and intermittent. It was associated with chills,non drenching sweats and headache which was felt on the occipital part. However the patient denies seizures and dizziness Did tepid sponging to reduce the fever and would take panadol to relieve the headache .

5. CONT’D Abdominal pain E pigastric region and right hypochondrium . A cute onset and burning in nature. R adiation to the back . Pain was continous and exarcebated by eating food such as beans, potatoes and coca cola. R elieved by panadol . S everity 10/10 as the patient couldn’t manage to walk or do anything.

6. CONT’D Patient also presented with yellowing of eyes for 5 days. This was preceded by passage of dark urine, no dysuria and hematuria. It was associated with itching of the skin. Loss of appetite and not opening bowels for 4 days (color of stool could not be noted) Patient could pass flatus However the patient denies nausea,vomiting , weight loss and abdominal swelling.

7. REVIEW OF SYSTEMS Respiratory system No chest pain No cough No difficulties in breathing Cardiovascular system Palpitations No easy fatiguability No shortness of breath No ankle swelling

8. Musculoskeletal system No joint pain No joint swelling No rash

9. PAST MEDICAL HISTORY RVD-NR (Verbally) Third admission with the previous two being due to two caesarian sections (1 st -2005 2 nd -2017) No Diabetes,Epilepsy,Asthma,Tuberculosis,Hypertension nor sickle cell.

10. DRUG HISTORY No known drug allergies Not on any medication besides the one being given in the ward. No use of herbal medication FAMILY HISTORY Epilepsy – brother’s child No diabetes, asthma ,TB, hypertension and sickle cell anaemia

11. GYNAE HISTORY Patient reached menopause last year April. Not on any contraceptives nor hormonal therapy. She has 2 children

12. SOCIAL HISTORY No alcohol No smoking No history of contact with any water bodies Stays with the husband and children No history of recent travel out of Lusaka No one else has similar symptoms in family and community

13. SUMMARY Presenting female,45 of RVD Unknown status who presented with intermittent fever for one week associated with sweating,chills and headache. A bdominal pain in the Right Upper Quadrant for one week associated with loss of appetite and not opening bowels for 4 days but with passage of flatus. J aundice for five days associated with passage of dark urine and pruritus. No history of seizures,vomiting,abdominal distension,weight loss,hematuria,dysuria , contact with any water bodies,use of contraceptives,hormonal therapy and no history of recent travel.

14. IMPRESSION Obstructive jaundice secondary to acute cholangitis DIFFERENTIALS Cholecystitis Choledocholithiasis Hepatitis Pancreatitis Cancer of the pancreas head Cholangiocarcinoma Mirrizi syndrome Severe Malaria Peptic ulcer disease

15. PHYSICAL EXAMINATION C onsent was obtained Pt was lying in supine position @45⁰ Patient was exposed from nipple area to level of pubic symphysis(normally should be mid-thigh). At the foot-end of the bed;i examined an adult female patient General appearance Patient was conscious and alert, N ot in respiratory distress ,had a cannula,no urinary catheter and no oxygen cylinder at the bedside.

16. CONT….. Yellowing of the sclera was noted Abdomen was rising with respiration Not cachexic

17. VITALS Admission Day of clerking BP 98/66 mmhg BP 117/77 mmhg Temp 38.0◦C Temp 37.8◦C RR 23 bpm RR 21 bpm PR 94 bpm PR 86 bpm SPO2 97% on room air SPO2 99% on room air

18. ON CLOSE EXAMINATION Hands Dorsum No leukonychia No koilonychia No finger clubbing CRT < 2 Seconds Palm Yellow palms were noted No palmar erythema

19. CONT…. No dupuytren’s contracture No scratch marks No asterixis Pulse 86 bpm strong with full volume, regular Pt was Febrile to touch Head and Neck Yellowing of the sclera was noted No xanthelasma No conjunctival pallor No glossitis

20. CONT…….. No yellowing of buccal mucosa No angular stomatitis No lymphadenopathy(Virchow’s triad)

21. GIT EXAMINATION Inspection Abdomen was mildly distended Umbilicus was Inverted(normal) Fresh traditional tattoos were noted in the epigastric region Caesarean scar was noted No scratch marks No caput Medusae No spider nevi on chest & upper body

22. PALPATION Light Palpation Soft Tender in epigastric region and Right hypochondrium Deep Palpation Murphy’s sign was positive Hepatomegaly about 10cm below the costal margin No splenomegaly Gallbladder not palpable

23. PERCUSSION The abdomen was resonant But dull on right hypochondrium below the right costal margin No shifting dullness Auscultation 4 Bowel sounds were heard in 1 minute DIGITAL RECTAL EXAM (Patient was not coparative )

24. CHEST EXAMINATION Inspection: No scars,no chest deformity, symmetrical chest expansion Palpation :Apex beat palpable at 5 th intercostal space Percussion: Resonant (Respiratory System) Auscultation: CVS- S1S2 regular No murmurs : RS- Vesicular breath sounds Bilateral air entry No crackles

25. LOWER LIMBS No pitting edema SUMMARY Examined an adult female patient with scleral jaundice noted on inspection,Febrile to touch,tenderness on epigastric region and right hypochondrium on light palpation with hepatomegaly and positive murphy’s sign. Patient not cachexic,no shifting dullness,no finger clubbing,no palmar erythema,no caput medusa,no pitting edema,no mumurs,no crackles.

26. IMPRESSION Obstructive Jaundice 2⁰ to Acute Cholecystitis DIFFERENTIALS Ascending Cholangitis Choledocholithiasis Cancer of the pancreas head Cholangiocarcinoma Choledocholithiasis Mirrizi syndrome Pancreatitis

27. INVESTIGATIONS LAB INVESTIGATIONS FBC-WBC raised( cholecystitis ), eosinophilia( schistosomiasis ) - Hb low & thrombocytopenia LFTs & LE-Increased total bilirubin and direct bilirubin -Mild increase AST&ALT -ALP and GGT levels high -Albumin low -Clotting profile-PT is prolonged Hepatitis serology- HBsAg,HCV Urinalysis – bilirubin present , urobilinogen absent Stool M/C/S for ova and parasites Stool for occult blood- Pancreatic Ca Tumor marker test eg CA 19-9, alpha fetoprotein HIV testing

28. IMAGING Abdominal Ultrasound ERCP – Gold Standard (diagnostic and therapeutic) MRCP – Best non invasive diagnostic CECT

29. s

30. URINALYSIS

31. Diagnosis Choledocholithiasis

32. MANAGEMENT MEDICAL CARE Treat the underlying cause eg -Cancer(chemo & radiotherapy) -ERCP if its gallstone - Albendazole if its schistosomiasis -Don’t give drugs which cause the sphincter to cause pain Symptomatic Mx - Painkillers,Antibiotics,cholestyramine for pruritus Treat the complication

33. CONT…….. SURGICAL Laparoscopic cholecystectomy remains the Tx of choice for symptomatic gallstones

34. CONT…….. What the patient has been receiving Ceftriaxone 1g BD IV Septrin 960mg BD PO Omeprazole 20mg BD PO Buscopan (Scopolamine-Antispasmodic drug) 20mg BD IV Enema IV fluids Albendazole 400mg PO STAT Cholestyramine 4mg OD PO