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Case Conference

Case Conference. Presented by: GAW, Gem Minnie Mae GO, Stephanie M. GONZALES, Alexander II. General data:. L.D.L. 50/F Filipino Roman Catholic Married High school graduate Date of admission: February 1, 2012 Informant: patient. Chief complaint:. Abdominal pain.

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Case Conference

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  1. Case Conference Presented by: GAW, Gem Minnie Mae GO, Stephanie M. GONZALES, Alexander II

  2. General data: • L.D.L. • 50/F • Filipino • Roman Catholic • Married • High school graduate • Date of admission: February 1, 2012 • Informant: patient

  3. Chief complaint: • Abdominal pain

  4. History of Present Illness

  5. History of Present Illness

  6. History of Present Illness

  7. Review of Systems • General: no weight loss/gain • Skin: no rashes • HEENT: no blurring of vision, no itching, no discharge, no changes in hearing acuity, no tinnitus, no ear pain, no ear discharge, no epistaxis, no nasal discharge, no gum bleeding • Respiratory: No cough, no dyspnea, no hemoptysis • Cardiovascular: No chest pain, no orthopnea, no easy fatigability • Gastrointestinal: HPI • Genitourinary: No dysuria, no incontinence • Musculoskeletal: No joint pain, no muscle pain, no weakness • Neurological: No headache, no seizures • Endocrine: No heat and cold intolerance, no palpitations, no tremors • Psychiatric: No anxiety, no depression, no hallucinations • Hematologic: No easy bruising, no prolonged bleeding

  8. Past Medical History • (-) Hypertension • (-) Diabetes mellitus • (-) bronchial asthma • (-) Pulmonary TB • (-) allergy • (-) blood dyscrasia • No previous surgeries and blood transfusion

  9. Family History • (+) Hypertension – mother and father • (-) Diabetes mellitus • (-) bronchial asthma • (-) cancer • (-) blood dyscrasia • (-) gall bladder disease • (-) kidney disease • (-) heart disease

  10. Personal and Social History • Non-smoker • Non-alcoholic beverage drinker • Mixed diet of chicken and meat (prefers fried and salty food), occasional vegetables and fish, drinks 3-4 glasses of water a day

  11. Gynecologic and Obstetrical History • Menopause: 47 y/o • G2P2 (2002) • No complications • No miscarriages • No abnormal vaginal discharge • No history of OCP use

  12. Physical Examination • Conscious, coherent, oriented to time, place, and person, ambulatory and not in cardiorespiratory distress • BP 130/80 mmHg PR 92 bpm,regular RR 21 cpm, regular T: 36.9 °C • Height 160.02 cm Weight 64 kg BMI 25 kg/m2 • Warm moist skin, no active dermatoses, (+) jaundice • Pink palpebral non hyperemic conjunctivae, ictericsclerae, pupil 3 to 4 mm ERTL, (-) eye discharge • No nasoaural discharge, midline septum, (-) mass • Moist buccal mucosa, non hyperemic posterior pharyngeal wall, no tonsillar enlargement • No tragal tenderness, non-hyperemic external auditory meatus • Supple neck, thyroid not enlarged, no distended neck veins, no palpable cervical lymphadenopathies

  13. Physical Examination • No chest deformities or asymmetry; no tenderness nor palpable masses, symmetrical chest expansion, equal vocal and tactile fremiti, clear breath sounds

  14. Adynamicprecordium, AB at the 5th LICS MCL, S1 louder than S2 at the apex, S2 louder than S1 at the base, no murmurs JVP 3cms at 30° CAP rapid upstroke and gradual downstroke

  15. Physical Examination • Flabby abdomen, soft, (+) whitish striae, normoactivebowel sounds, (+) murphy’s sign, (-) CVA tenderness, (-) mass

  16. Physical Examination • Pulses full and equal, no cyanosis, no edema • No tenderness of joints, no swelling, no limitation in ROM

  17. Neurologic Examination • Mental Status: conscious, coherent, oriented to time place and person, awake, follows commands • GCS 15 (E4V5M6) • Cranial nerves: (-) anosmia, pupils 3-4mm ERTL, OD no visual field cuts, EOM movement intact, OD; V1V2V3 intact, can raise eyebrows, can smile, can frown, intact gross hearing, uvula midline, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion • MMT 5/5 on all extremities, can do FTNT and APST • (-) Babinski’s sign, (-) NuchalRigidity, (-) Kernig’ssign, (-) Brudzinki’s sign

  18. Assessment: • Obstructive jaundice secondary to cholelithiases

  19. Plan: • Open cholecystectomy with IOC

  20. Diagnostics • Ultrasound • initial investigation • noninvasive, painless, no radiation • dependent upon the skills and the experience of the operator

  21. Biliary Radionuclide Scanning (HIDA Scan) • a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information • diagnosis of acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum

  22. Computed Tomography • differential diagnosis of obstructive jaundice

  23. Percutaneous TranshepaticCholangiography • An intrahepatic bile duct is accessed percutaneously with a small needle under fluoroscopic guidance. • it defines the anatomy of the biliary tree proximal to the affected segment • useful in patients with bile duct strictures and tumors

  24. Magnetic Resonance Imaging • provides accurate anatomic details of the liver, gallbladder, and pancreas similar to those obtained from CT

  25. Endoscopic Retrograde Cholangiography • requires intravenous sedation for the patient • include direct visualization of the ampullary region and direct access to the distal common bile duct, with the pos • the diagnostic and often therapeutic procedure of choicesibilityof therapeutic intervention • Complications include pancreatitis and cholangitis, and occur in up to 5% of patients.

  26. Operative Interventions for Gallstone Disease • Cholecystostomy • applicable if the patient is not fit to tolerate an abdominal operation

  27. Cholecystectomy • most common major abdominal procedure • Laparoscopic Cholecystectomy • minimally-invasive procedure, minor pain and scarring, and early return to full activity. • treatment of choice for symptomatic gallstones • Open Cholecystectomy • safe and effective treatment for both acute and chronic cholecystitis

  28. Intraoperative Cholangiogram • The bile ducts are visualized under fluoroscopy by injecting contrast through a catheter placed in the cystic duct . • Their size can then be evaluated, the presence or absence of common bile duct stones assessed, and filling defects confirmed, as the dye passes into the duodenum.

  29. Choledochal Drainage Procedures • stones cannot be cleared and/or when the duct is very dilated (larger than 1.5 cm in diameter) • Choledochoduodenostomy • performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct

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