Case summary : :

8/1/14 Day 1 ::

- Fever spikes-

- Inject.Ampicillin 800mg i.v qid.

- Decreased appetite-

- IVF DNS 10% D with MVI –tid.

- Bowel not passed ( used to be clay coloured

- Injection Zofer 4mg iv/stat/ sos

- Micturition : Normal, Yellow in colour with reddish tinge

- Syp.Sucral 6ml tid

- O/E :: Icterus : positive, pallor positive.

-

- Syp.Parasafe 5ml sos

- H.R : 100/min.- R.R : 30/min.- P/A : Soft, Hepatomegaly.

-

- Injection vitamin k 5mg i.v/od- Syp.Hepamez 6ml tid.- Glucon D in water- FFP transufusion sos.- Syp. Lactulose 15 ml BD- Tab.Udiliv 150 mg ½ tab bd

- Advice :- Serum amylase and lipase.

-

9/1/14 & 10/1/14 : Patient condition same with same line of treatment.

10/1/14 ::

On examination :1. Mass abdomen.2. Jaundice with clay stools

with no itching.3. Abdomen pain vague

nonspecific and non localized.

4. No lymphadenopathy5. Mass is nodular, non tender,

firm to hard mass continuous with liver.

6. GB not serpartely felt.7. Spleen not palpable.8. No abdominal wall lesions.9. No bony mass and both

testes normal.

Review of investigations :1. PT :16.5/13.52. APTT :29.5/30.3. LFT :12mg/8.7MG %4. Alkaline phosphatase 1578

IU/L.5. BT/CT: WNL .6. S.Albumin 3.4 %7. Total protein : 6.8 %8. Total Hb : 9.6 gm%9. TLC: 10.6 /cumm3.

10. Amylase :140 u/l/11. Lipase :200 u/l.12. USG : Dilated CBD with

IHBD. Mass in and around Dudodenum and head of pancreas . No calcification.

13. CECT : Both lung bases within normal limits.

14. No mass seen.15. No pleural effusion.

Draw diagram ::

Impression : Extra duodenal/ peri pancreatic retroperitoneal tumour with out calcification with obstructed dilated common bile duct.And infiltration of duodenum / head region and proximal / hepatic flexure.

D/D : 1. Neuroblastoma. 2. Lymphoma.

Clinicals : Stage III and beyond.

PLAN ::

Exploratory laparotomy with debulking and common bile duct drainage and with duodenal /colonic by pass.

10/1/14 ::

1.Proctolysis enema.2.Serum electrolytes.3. Consent and Pre anaesthetic consult taken.4.Blood of 2 units with 2 packed cells volume and fresh frozen plasma 2 units.5. Parents of the child have been informed that CBD is obstructed and dilated and is responsible for jaundice.6. CECT scan performed shows big tumour around distal CBD, proximal gut and head of pancreas and proximal colon i.e a cancer tumour.7. The treatment planned is surgical removal as much of tumour as possible by biliary drainage and by pass duodenum /colon.8.That after the pathology report, child requires RT/chemotherapy for he would be refered to cancer hospital.9. That the disease is cancer and there is risk to life.

10. Surgery is major and involves use of blood and blood products.11. Huge tumour around duodenum and pancreas with CBD obstruction was posted for debulking/ triple by pass /modified whipples.12. Operation : Inverted T proposed incision with exploratory duration of 3-4 hrs.

11/1/14 ::

1. Extended whipples operation : Huge tumour near distal Common bile duct and transverse mesocolon , jejunal mesentery.

2. Dilated common bile duct.3. Small lymph nodes in mesentery.

Post operative instructions ::1.N.P.O.2.NGT asp.3.Elevate the head end.4. IV fluids : PMS 1400ml/24hrs.5. Injection monocef 1.5 gms bd.6. Injection. Metrogyl 4.0 ml/iv/ 8th hourly.7. ½ hour colon cry /HR/R.R / HR chart.8. Hourly urine out put.9. Neomol 150 mg/ 8th hourly.

12/1/14 ::General condition fair. No fresh complaints.POD 1 :Subjective :1. Following extended whipples .2. Passed urine 7-8 3. NGT asp – 200 greenish .4. DT collection 300 ml greenish.5. Verbal rating scale : 2/106. Ambulate in bed.

Objective findings ::

1. Pulse : 120/min.2. Temp : 99 o C.3. VRS : 2/10.4. Dressing insitu , Soft no distension.

5. Chest clear with bilateral air entry.6. Drain tube with greenish bile.

Assessment :: 1. Pain : 1/10.2. DT :300 ml .3. NGT green.

Plan ::

1. Sips2. Mouth care.3. NGT aspirations hourly and contininous drainage.4. Deep breathing exercises.5. Saline nebulisations.6. Balloon inflation.7. Ambulation.8. IV fluids : RL 500 ml and PMS 1400 ml with 1ml kcl over 100

ml.9. Inj. Monocef and metrogyl to continue.10. Neomol suppository 8thr houly.11. Icecream small amounts 12. Proctoclysis enema.

13/1/14 ::

Subjective findings ::

1. Extended pancreaticoduodenectomy.2. Temp:99 0 F.3. Talking .4. Passed motion twice.

5. Ambulatory.

Objective findings ::1.Pulse :90/min.2.VRS: 2/10.3. Wound healthy no redness or induration.

Assessment ::1.Child stable.2.No vomiting and discomfort.

Plan ::1. Injection Monocef 1.5 gm/i.v/bd.2. Injec. Metrogyl /30 ml/i.v/tid.3. Sips of fluids.4. Neb. With saline.5. Mouth care.6. Breathing exercises.7. IVF PMS.8. Siladerm for L/A .9. Advice for blood urea, serum creatinine and serum

electrolytes.

14/1/14:: Subjective::1.Temp : 101 o F.2. Passed motion.3. No vomiting.

4. DT <200 ml.

Objective ::1. VRS: 2/10.2. S.Bilirubin :3.9 with direct 2.9.3. TLC :39004. Albumin :3.1 gms %5. Hb :10.2 gm.6. Alk :562 u/l.7. OT: 52.8. PT:50.