VIRTUAL ROUNDFEMAL BAY (BED 27-30 &39-42)Dr. Verdah SabihHouse SurgeonSU-2 BBH

BED# 27: Patient tasleem ,31

yr/ F, admitted(24-5-15) via ER with S/S of obs. Jaundice:

Yellowish discolouration of sclera ---- 1 yr

Dark coloured urine & pale stools ---- 1 yr

Generalized itching ----1 wk

Pt a k/c of obs. jaundice,. 2 yrs back her cholecystectomy was done after which she developed biliary peritonitis for which exploratory laprotomy was done. T-tube was placed after CBD exploration.then pt.was admitted for obs.jaundice. ERCP was done in BBH & HFH, no stenting was done.

no H/o fever,vomiting,abd pain.General physical exam: a young lady lying comfortably in bed, well

oriented in TPP,with visible jaundice & vitals of:

B.P= 110/70 pulse=78/min Resp rate= 16/min temp=A/F Urine o/p=2800ml/24hrs

SYSTEMIC EXAMINATION: GIT: scaphoid symmetrical abdomen with

central umblicus. Soft, non-tender Tympanitic note BS +ve Rest of systemic examination

unremarkable.

Current status: s/s of obs jaundice still persist. Itching has markedly decreased. No other active complaints.

CURRENT TREATEMENT: Inj. CEFTRIAXONE 1g I/V B.D Inj. RISEK 40mg I/V O.D Inj. VIT.K I/M on alternate days CHOLESTYRAMINE sachet P/O T.D.S Inf. N/S 1L I/V B.D Inf. 10% D/W 1L I/V O.DInvestigations: (most recent labs 2-6-15) TLC=9.6 (neutro’s 78%) Hb=9.5

PLT=307 TBIL=35 ALT=19 ALP=182 AST=41 UREA=16 CRET=0.4 Na=138 K=4.5

Date TBIL

25-5-15 45.4

26-5-15 40

28-5-15 39.7

29-5-15 35.9

30-5-15 38.7

1-6-15 32.9

2-6-15 35

PT=17/14 APTT=34/32

URINE R/E:yellow color,ph=7.0.sp.gravity=1.070, albumin=nil.glucose=nil, pus cells=6-8 ,RBC=2-3

ERCP: (10-4-15) BBH Stricture at mid CBD. ERCP: (15-4-15) HFH Partial sphincterotomy

done.CBD cannulated upto level of cystic duct.guide wire could not be passed further.possibility of tight stricture.

USG Abd & Pelvis: (26-5-15)

septated ascites,localized collection in subhepatic region

B/L grade 1 RPD Intrahepatic cholestasis

CT abdomen & pelvis: (28-5-15)

hepato-splenomegaly with intra hepatic cholestasis, dilated portal vein & septatecf ascites.

PLAN: On next possible list for

choledochojejunostomy.

BED# 28: Bushra 30 yr/F ,admitted (19-5-15) through

opd with complaints of: Pain & numbness in RT arm ---- 3 months. Pain started 3 months back at wrist joint

&slowly progressed, for which she went to orthopedics dept HFH,where she was diagnosed as having fracture wrist & POP cast was applied.but after the application of cast her hand started becoming cyanosed so cast was removed. Pain in Rt arm persisted & an exacerbation was seen in pain & cyanosis upon movement of arm.pain is persistent,transiently relieved by analgesics.

GENERAL PHYSICAL EXAMINATION: A young,healthy woman,sitting comfortably

on bed,well oriented in TPP,with vitals: B.P=130/80 pulse=87/min(normal

rhythm,low volume) Resp rate=19/min temp=A/FSpecific examination of upper limbs:

Oedema –ve Cyanosis +ve Rt arm. Inc. on movement Pallor –ve No wasting of muscles of arm & hands. No patchy gangrene or finger top necrosis

Rt radial pulse not palpable.Rt brachial pulse weakly palpable.B.P of RT upper limb=110/80B.P of LT upper limb=140/80A bony swelling palpable in RT supraclavicular

fossa above clavicle.A pulsatile mass palpable in RT supraclavicular

fossa.Bruit over RT subclavial artery +veSensations in all dermatomes of B/L upper

limbs---intactMovements & range of motion around all joints

of upper limbs---normal.Rest of systemic examination

unsignificant.

PROVISIONAL DIAGNOSIS: Rt thoracic outlet obstruction.

Current treatment: Cap. NEUROBION 1cap P/O O.D Tab. NIMS 1tab P/O B.D

Current status: Pain in RT arm persistent. No other active complaint.

INVESTIGATIONS: TLC=7.2 Hb=13.2 PLT=282 PT=16 APTT=30 TBIL=1.5 ALP=57 ALT=18 UREA=25 CRET=0.5 Na=135 K=3.7 URINE R/E=no significant findings HEP B& C serology= -ve CXR= unremarkable THORACIC INLETx-ray=B/L cervical ribs.more

pronounced on RT side

ARTERIAL DOPPLER RT upper limb (25-5-15):

Triphasic & normal velocities in RT subclavian, Rt axillary & Rt brachial arteries.

Rt radial & ulnar arteries could not be appreciated.

Echocardiography (30-5-15):

Normal sized LV with normal systolic function.

Ejection fraction 60% Normal valves,RV/RA.

CT Angiography Rt upper limb (1-6-15):

Right cervical rib without any compression on Rt limb vessels.

PLAN: On next possible list for modified b??????

Procedure.

BED # 29 Mehwish 20 yr/F admitted (26-5-15) via OPD

with C/O: Swelling infront of neck----2 yrs Dyspnea,dysphagia ----- on & off occasional

episodes. Swelling developed infront of neck 2 yrs back

gradually, moves with swallowing,gradually increasing in size,associated with dyspnea & dysphagia on & off occasional episodes.

No H/o weight loss/gain,diarrhea/constipation, cold/heat intolerance,sweating.

GENERAL PHYSICAL EXAMINATION: A young woman of avg height & built,sitting

comfortably on bed,well oriented in TPP,having vitals:

B.P=110/70 pulse=72/min RR=16/min Temp=A/F

Local examination: Unsymetrical swelling 6x5cm,moves with

swelling.normal overlying skin. Firm,well defined margins. No lymph nodes

palpable.nodular surface.not attached to overlying skin.

Bruit –ve. Pemberton sign –ve. Rest of systemic examination unremarkable.

PROVISIONAL DIAGNOSIS: Simple multinodular goiter with compressive

symptoms. Current status: No active complaints. Investigations: TLC=11.2 Hb=10.2 PLT=462 TBIL=0.6 ALT=25 ALP=63 AST=32 UREA=15 CRET=0.5 PT=16 APTT=45 Na=139 K=4.2 HEP B& C serology= -ve Total T3=94 total T4=7.90 TSH=1.05 FNAC=consistent with adenomatous colloid

goiter

CXR=unremarkable THYROID SCAN=

multinodular goiter with warm nodule- L1 & cold nodules B/L.

PLAN:on next possible list for near total thyroidectomy.

BED # 40: Rabia bibi 50 yr/F admitted through OPD with

C/O: Lt sided chest pain------ 2 months Fever------ 2 months Cough-----2 months SOB------ 2 months Fever was low grade associated with night

sweats.cough was associated with hemoptysis on & off.SOB setteled after intubation in quetta.then pt came to CMH where chest tube was readjusted but pain did not settle.

Pt had T.B 10 yrs back for which she took ATT but course was not completed.

Recent h/o T.B contact +ve.

GENERAL PHYSICAL EXAMINATION: A middle aged woman lying comfortably in

bed,well oriented in TPP, with chest tube placed in left side chest, vitals of:

B.P=110/80 pulse=82/min RR=24/min temp=A/F Respiratory system exam: Decreased chest movement of Lt side. Decreased chest expansion on Lt side Dull percussion note on Lt side Decreased air entry on Lt side

Rest of systemic exam unremarkable.

PROVISIONAL DIAGNOSIS: Lt sided pleural effusion with collapsed lung.

Current treatment: Inj. CEFTRIAXONE 1g I/V B.D

Current status: No active complaints.

INVESTIGATIONS: (27-5-15) TLC=7.2 Hb=13.3 PLT=366 PT=17 APTT=34 TBIL=0.5 ALT=21 ALP=86 AST=24 UREA=25 CRET=0.4 Na=136 K=4.0 AFB smear of pleural fluid= -ve Histopath report=haemorrhaic

background,acute inflammation.-ve for malignancy.

PFT’s (30-5-15) : FEV1 change ~19

(reversibility) Both obstructive &

restrictive pattern of airway disease.

Echocardiography:

Report awaited.

PLAN: On next possible list for pleural decortication.

CT chest: (14-5-15) large Lt hydro-pyo-

pneumothorax. Non-specific

consolidation in Lt lower lobe.

small 07 mm nodule/granulomain Rt lower lobe.