long case writting of 80 years old female with right hypochondriac region mass.

1. Presented By :
Intern doctor Amit Kumar Shah
Intern doctor TythiKundo
Department of surgery

2. Particulars of the patient:
 Name: Mrs. Suraton
 Age : 80 years
 Sex: Female
 Adress: bangla Heli, Hakimpur,DinajpurSadar
 Marital status: Widow
 Religion: Islam
 Date of admission: 07-11-2022@7:14 PM
 Date of examination: 07-11-2022@7:30 PM

3. Chief Complaints:
1. Pain in the upper abdomen for 4
months.
2. Loss of appetite for 3 months.
3. Weight loss for 3 months.

4. History of present illness:
She was apparently alright 4 months
ago when she start experiencing
episodes of sudden onset of pain in
right upper abdomen which is colicy in
nature radiating to back in the
shoulder occurring around 20 to 30
minutes after meals and subsides on its
own after an hour or two.

5. She experiences this episodes daily
associated with feeling of fullness in
upper abdomen after taking meals but
no complaints of heartburn. From the
last1 month she start having dull
aching pain in the right abdomen
which was continuous in nature not
radiating to back, more after taking
meals and do not subsides completely.

6. She also gives history of loss of appetite
which let her to lose weight of 8-10 k kg
in last 3 months but this was not
associated with abdominal distension,
nausea or vomiting .There is no history
of yellow colouration of eyes or skin,
high colour rine or itching over the
body

7. There is no history of fever , no history
of altered bowel habit, no history of
blood in the stool or black colored
stool. There is no history of lump in the
abdomen or swelling in the neck or
other part of body . No history
breathlessness, cough, or chest
tightness.

8. History of past illness:
Hysterectomy was done for uterine prolapse 2
months back.
She is hypertensive and on medication for
last 5 years and has no history of DM,
asthma, tuberculosis.
Immunization History:
She is immunized as per EPI schedule. She is
immunized against HBV. (For surgeon’s
safety)

9. Personal history:
No addiction
Bowel and bladder habit normal
Sleep and appetite decreases
Mixed bengali diet

10. Family History
No history of gallbladder stone disease
in any family member
No history of malignancies in her any
family member
No history of liver disease

11. Menstrual history
She attains menopause at the age of 47
years and previous menopausal history
is unremarkable .
Obstetric history
she have 5 childrens and age of last
child born is 45 years.

12. Drug history:
She took anti- Hypertensive drug and
also took some tablets from local quack
but could not mention the names.

13. General Examination
Patient was examined in well lit room
after obtaining consent in presence of
female attendant
 Conscious, co operative and well oriented to
time, place and person
 Lean, thin,well hydrated, lying confortably
in bed with iv canulla in left hand and
cathetrized
 Temperature: 98.6 (Right axilla)

14. Pulse : 76min regular rhythm (right
radial artery)
BP: 130/80mmhg ( right arm supine
position )
RR: 14/ min
Anemia:mild anemic

15.  Non icterus, cyanosis, clubbing, koilonychias,
leuconychia were absent
 Lymphoneds are not enlarged , no bipedal edema

16. Abdominal Examination:
Examined on the supine position with
arm kept on sides and exposed from
lower chest to pubic tubercle( after
taking consent again and in presence of
female attendant)
INSPECTION:
Abdomen was normal in shape with a
central and inverted umbilicus and
vertically slitted.

17. Overlying skin was normal with an scar
of previous surgery ( lower midline
incision),there was no dilated veins,
visible pulsation , peristalsis absent
All quadrant moves equally with
respiration and is thoraco- Abdominal
No visible lump in any of the quadrant
nor was any swelling at hernial site

18. Palpation:
Temperature was not raised
There is no superficial tenderness
The abdomen is soft
There is a single globular lump
palpable in the right hypochondriac
region around 4cm X 3 cm extending
1cm lateral and 3 cm medial to right

19. midclavicular line and extending 3cm
below the right costal margin. The
surface is irregular, margins are well
defined , is hard in consistency and
moves well with respiration. It become
palpable when patient is asked to
raised a head.

20. There is no evidence of hepatomegaly and
spleenomegaly or any other lump. Hernia
sites are normal.
Percussion:
Abdomen is tympanic on percussion. But
the lump is dull on percussion and is in
continuation with the dullness of liver
which ends at the 6th ICS in the mid
clavicular line

21. Auscultation:
 Normal bowel sound are audible and no
hepatic bruit
On D/R/E: Yellow staining of examining
figure is noticed and no mass detected

22.  On cardiovascular examination and respiratory
examination revels no abnormalities , nervous
system ……

23. Case summery :
Mrs. Suraton, 80 years old hypertensive,
non diabetic lady resident of Bangla
Heli, Hakimpur, Dinajpur sadar got
admitted to TMC & RCH with the
complaints of episodes of colicy right
upper quadrant pain for last 4 months
which change to dull aching
continuous pain for last 1 month
without any jaundice or bowel habit
alter.

24. She also gives history of loss of appetite
which let her to lose weight of 8-10 k kg
in last 3 months but this was not
associated with abdominal distension,
nausea or vomiting

25. On examination she is lean but pale
lady without icterus , single hard lump
in the right hypochondrium 4X3 cm
with well defined margins and irregular
surface moving well with respiration ,
lump was dull on percussion. There is
no clinical evidences of ascitis and this
mass is likely to arise from gall bladder.

26. Provisional Diagnosis:
Gall bladder malignancy

27. Differential Diagnosis:
„Mucocele of gallbladder
 „Empyema of gallbladder „„
Periampullary carcinoma „
Cholangiocarcinoma involving the
distal bile duct „

28. Investigation:
„Ultrasonography of
whole abdomen :
 Suggestive of gall
bladder mass.
 Hydronephosis(
bilateral)
 And H/O
hysterectomy with
inflammed stump.
And patient is
adiviced to do CT
abdomen but
patient refuse.

29.  Patient refuse to pay test for CT scan of abdomen, so
we advice the patient CEA and CA 19-9 , it is increased
in other GI malinancy but if we suscpect Ca gall
bladder CEA and CA 19-9 will be absolutly raised .
 CEA:153 ng / mL ( <5ng/mL)
 CA 19-9 : >1000.00 U/mL ( normal < 35)

31. CBC:
 Hb: 9.60%
 ESR: 72 mm at 1st
hour
 TC: 14.60 k/uL
 DC: N- 79% ; L- % ;
M-1% ; E- 05% ; B-
00%
 Microcytic
hypochromic anemia
with neutrophilic
leucocytosis.

32. Random Plasma
Glucose :
5.80mmol/
Serum
Creatinine:1.36
mg/dL
Blood Grouping
and Rh factor:
“o” positive

33.  Urine R/E showing
8-10/ HPF pus cell,

34. Confirm Diagnosis:
Gall bladder carcinoma

35. Treatment:
1. Pre-operative preparation.
2. Surgery: If the disease is localized
and there is no distant spread then I
will plan for curative surgery. I will do
an exploratory laparotomy and assess
the operability and if it is operable I
will do radical cholecystectomy

36. 3. with advanced gallbladder cancer
These patients need palliative treatment
only:
„Palliation of jaundice: ERCP and
stenting with a self expanding metallic
stent provides relief of jaundice with
less need for repeated change of stent. „

37. Palliation of gastric outlet obstruction:
Gastric outlet obstruction may also be
relieved by endoscopic duodenal
stenting or by open operation of
gastrojejunostomy. „
Palliation of pain: NSAID → Opioids
→ percutaneous neurolysis of celiac
plexus by injecting alcohol.

38. Chemotherapy is not very effective in
carcinoma gallbladder. Most frequently
5-fluorouracil and mitomycin have
been used. Cisplatin has shown better
results
Radiation therapy has been used after
resectional surgery as an adjuvant.

39. No survival advantage has been
reported. Radiation sensitizer 5-
fluorouracil along with radiation
provides some benefit. Advanced
unresectable disease radiotherapy is
not useful.
Prognosis: 5-year survival rate < 5%

40. Thank you