Write well organized medical history of the the following patient who is presented with epigastric burning pain of 2 month duration that radiates to his back . The patient also complains yellow discoloration of the eye , loss of apetite itching , dark urine.
The patient also notices a swelling in his right upper quadrant.
On physical examination he has icteric sclera and a mass in his right upper quadrant.
Include pertinent positves and negatives( consider those are not written above as negative), risk factor and complications for obstructive jaundice.
Also include the possible cause of the obstructive jaundice.
Medical History:
Chief Complaint: Epigastric burning pain radiating to the back for 2 months, yellow discoloration of the eye, loss of appetite, itching, dark urine, and swelling in the right upper quadrant.
Present Illness:
The patient presents with a 2-month history of epigastric burning pain that radiates to the back. Additionally, he complains of yellow discoloration of the eye, loss of appetite, itching, dark urine, and a swelling in his right upper quadrant. The pain has been constant and has not improved with any over-the-counter medications. He denies any fever, nausea, vomiting, or changes in bowel movements.
Medical History:
The patient has a past medical history of hypertension for which he takes an ACE inhibitor. He denies any surgical history or other significant medical conditions. Family history is non-contributory.
Social History:
The patient is a non-smoker and denies any alcohol or recreational drug use. He is currently unemployed and lives alone.
Physical Examination:
On physical examination, the patient appears icteric. He has yellow discoloration of the sclera, suggesting jaundice. Palpation reveals a mass in the right upper quadrant, consistent with a swelling in this area. No other abnormalities are noted.
Pertinent Positives:
1. Epigastric burning pain radiating to the back.
2. Yellow discoloration of the eye (icteric sclera).
3. Loss of appetite.
4. Itching.
5. Dark urine.
6. Swelling in the right upper quadrant.
7. Mass palpated in the right upper quadrant.
Pertinent Negatives:
1. No fever.
2. No nausea or vomiting.
3. No changes in bowel movements.
4. No significant medical conditions or surgical history.
Risk Factors and Complications for Obstructive Jaundice:
Risk Factors:
1. Gallstones: Obesity, older age, female gender, rapid weight loss.
2. Pancreatic cancer: Smoking, obesity, family history of pancreatic cancer, chronic pancreatitis.
3. Biliary strictures: Previous surgery, inflammatory bowel disease.
4. Biliary tract infections: Presence of common bile duct stents, previous biliary surgery.
Complications:
1. Cholangitis: Infection of the bile ducts.
2. Liver failure: Due to chronic obstruction of the bile flow.
3. Malabsorption: Impaired digestion and absorption of fat-soluble vitamins.
Possible Causes of Obstructive Jaundice:
1. Choledocholithiasis: Gallstones obstructing the common bile duct.
2. Pancreatic neoplasm: Cancerous tumor in the pancreas causing biliary obstruction.
3. Biliary stricture: Narrowing of the bile ducts due to scar tissue formation.
4. Primary sclerosing cholangitis: Inflammatory condition causing biliary strictures.
5. Biliary tract infections: Infections leading to obstruction.
6. Mirizzi syndrome: Gallstones causing obstruction at the level of the cystic duct or the common bile duct.
Overall, the patient's presentation of epigastric burning pain, yellow discoloration of the eye, loss of appetite, itching, dark urine, and a swelling in the right upper quadrant is highly suggestive of obstructive jaundice. The yellow discoloration of the sclera and the palpable mass in the right upper quadrant further support this diagnosis. Further investigation, such as imaging studies and laboratory tests, will be required to confirm the underlying cause of the obstructive jaundice.