CASE PRESENTATION

PRESENTER: DR. VIJAY RANA JR3, DEPT OF GENERAL SURGERY

MODERATOR: DR. SURESH SAH SIR(HOD), DEPT OF GENERAL SURGERY ,
BPKIHS
DEMOGRAPHIC HISTORY
• NAME: RAMKALYA DEVI
• AGE/SEX: 65Y / FEMALE
• RESIDENT: JANAKPUR 02, DHANUSA
• RELIGION : HINDU
• OCCUPATION: HOUSEMAKER
• SOCIOECONOMIC STATUS: LOWER (AS PER MODIFIED KPS)
• INFORMANT: PATIENT HERSELF, RELIABLE
CHIEF COMPLAINT:

• PAIN IN RIGHT UPPER ABDOMEN SINCE 2 MONTHS

• MASS OVER RIGHT UPPER ABDOMEN SINCE 15 DAYS
HISTORY OF • The patient was apparantly well 2 MONTHS back when she
PRESENT experienced first episode of pain in right upper abdomen
ILLNESS: which was dull in onset, dull aching type, non radiating ,
non shifting, non migrating , aggravated by taking fatty and
spicy food and relieved with over the counter medication.
The pain was initially mild which she experienced about 3-
4 times over one and half month which since 15 days has
become continuous and increased in severity and pain has
decreased but not subsiding completely with otc medicines.
• There is no postural or diurnal variation in pain.

• The patient also complains of mass over the right upper

abdomen since 15 days, insidiuous in onset, which was
noticed by patient herself while taking bath. She gives
history of drastic increase in the size of lump which was
initially of size of lemon and that has progressed to current
size . There are no aggravating and relieving factors.
History of • History of unintentional weight loss present evidenced by
present loosening of clothes
illness contd..• History of loss of appetite present
• No history of yellowish discolouration of eye, passage of
clay colored stool or high coloured urine.
• No history of fever, night sweats, nausea and vomiting.
• No history of abdominal distension, or inability to pass
stool and flatus.
• No history of chest pain, hemoptysis, shortness of breath,
loss of consciousness, seizure or back pain.
• Normal bowel and bladder habits.
Past history: • No h/o similar illness in the past
• No h/o any chronic illness in the past
• No h/o enteric fever/viral hepatitis, jaundice in past.
• No hx of blood transfusion in past
• No hx of any abdominal surgery in past.

Personal • Married, postmenopausal and has two children( 1 son

history: and 1 daughter) and both are healthy.
• Patient does’nt smoke or consume alcohol.
• Vegeterian by diet.
• Normal sleep and with decreased
Family • No history of similar illness in the family
history: • No history of any biliary or gastrointestinal malignancy in
the family

• Patient had self medicated with over the counter

Treatment medicine . Initially patient took antacid which didn’t
history and relieve the pain and later changed the medication to OTC
drug allergy painkiller which decresed the pain.
hx: • Patient had visited the nearby hospital prior to visiting our
hoispital 2 weeks back due to severe continuous pain and
not relived completely with over the counter painkiller
where some workup and investigations were done and
was referred to our center for further workup and
management.
History summary:

65 yr elderly female belonging to low socioeconomic status, non

smoker non alcoholic presented to opd with complain of right upper
abdominal pain since 2 months which was dull aching type, on and off
type, relieved with otc medicines which has become continuous and
increased in severity since 15 days and she also complains of palpable
mass over same region since 15 days that has drastically increased in
since since then. It was associated with anorexia and significant
unintentional weight los without any history of jaundice and history
such events in the past or any malignancy in the family members.
General physical examination
Patient was examined after taking well informed consent in a well lit room with
proper exposure in the presence of female attendant.
Patient is conscious, co operative and well oriented to time , place and person , lying
comfortably on bed, with 20G canula in right hand , thin built AND measuring
Ht: 137 cm Wt: 33 kg with BMI: 17.58 kg per sq mtr
ECOG score: 1

VITALS:
BP: 130/80 , right arm in sitting position
PR: 80 bpm, regular, normal volume and character, no RR/RF delay, all peripheral
pulses palpable
RR: 16 cycle /min, abdominothoracic
Tempr: afebrile
General physical examination contd:
• No pallor, no icterus, no cyanosis, no dehydration, no clubbing, no
lymphadenopathy , no edema

• No sign of chronic liver cirrhosis present.

Systemic examination
Per • Inspection: falt, non distended, umbilicus central, all quadrants moving
abdomen: equally with respiration, no scar marks, no visible peristalsis, no
venous prominence, all hernial orifices intact

• Palpation:
• On superficial palpation: soft , non tender, no superficial rise in temperature

• On deep palpation: palbable tender mass involving right hypochondrium

extending to right lumber region and towards epigastric region, soft in
consistencywith nodular irregular surface with liver span of 17 cm in right
midclavicular line
• There is also pyriform shaped mass of size around 4*3 cm extending towards
umbilicus, firm hard in feel with irregular surface with ill defined border,
moving up and down with respiration, upper border not palpable, and non
tender on palpation.
• Percussion: tympanic note on persussion, shifting dullness absent.

• Auscultation: bowel sound present, 4-5/ minute

Digital rectal examination:

• Normal anal tone and normal mucosa.
• No any palpable mass. Finger stained with stool
Systemic examination contd:
Chest: • Bilateral equal air entry, normal vesicular breath sound

CVS: • S1S1(normal), no murmur

CNS: • Grossly intact

 • No anal growth, no anal fissures
DRE: • Normal anal tone and normal mucosa.
• No any palpable mass. Finger stained with stool .
Case summay:

• 65 yr elderly female belonging to low socioeconomic status, non smoker

non alcoholic presented to opd with complain of right upper abdominal
pain for 2 months which was dull aching type, intermittent and increasing
in severity since 15 days and palpable mass over same region since 15
days that has drastically increased in since then. It was associated with
anorexia and significant unintentional weight loss. No history of jaundice
and No such events in the past or any malignancy in the family members.

• On examination, she in non icteric with hepatomegaly with liver span of

17 cm in rt mid clavicular line with soft consistency and irregular nodular
surface with palpable gall baldder of size around 3*4 cm extending
towards umbilicus firm hard in feel with irregular surface and ill defined
border without any evidence of free fluid in the abdomen.
Provisional Diagnosis: 65 yr elderly female presented with pain in right
upper abdomen with change in pain nature recently and palpable
mass in right upper abdomen extending to rt lumber region and
epigastric region(hepatomegaly) – likely to have GB pathology most
likely carcinoma of Gall bladder with liver metastasis

Differential:
• Hepatocellular carcinoma
THANK YOU
Invx.
• To confirm the diagnosis
• To stage the disease
• To treat the patient