The document provides a case presentation on obstructive jaundice in a 43-year-old male patient. It includes demographic details, medical history, subjective and objective evidence from examinations and lab reports, medications, progress notes, assessments, care plan, pharmacist interventions, and patient education. The assessments determined the patient had obstructive jaundice likely due to periampullary carcinoma. Treatment included antibiotics, analgesics, vitamins, and surgery to remove the tumor, with the goals of reducing fever, itching, and jaundice which were achieved.

1. Department of Pharmacy Practice , Bengaluru
CASE PRESENTATION ONCASE PRESENTATION ON
OBSTRUCTIVE JAUNDICEOBSTRUCTIVE JAUNDICE
IP NO.
Presented To:
Asst professor
Pharmacy practice
Kcp
Presented By:
NARESH SAH
4th
year pharm-d
13Q1420
kcp

4. PATIENT DEMOGRAPHIC DETAILSPATIENT DEMOGRAPHIC DETAILS
AGE: 43yrs SEX: male HEIGHT: 153cm WEIGHT/Kg: 52kg BMI: 22.22
DOA: 7-9-16 DOD: WARD: SURGERY WING: 3
MEDICATION HISTORY: not recorded
MEDICAL HISTORY: no comorbidities
no surgeries
PERSONAL HISTORY:
bowels and bladder habits unaltered
DIET normal
Socioeconomic : wife, 1 daughter(1yr old), mother (aged home)
Patients is only the sole bread winner of the family.
ALLERGIES:no

5. SUBJECTIVE EVIDENCESUBJECTIVE EVIDENCE
CC:
 Generalized itching since 4 months. (cholestatic pruritis)
 Yellowish discoloration of skin and eyes since 3 months. (jaundice)
 Clay colored stools, ( indicates obstruction to bile flow=== stercobillin)
 high colored urine. (more conjugated billirubin excretion)
HPI:
 Patient was apparently normal 4 months back.
 then he suddenly started developing generalized pruritis followed by yellowish
discoloration of skin and eyes,
 clay colored stools and dark urine 3 months back
 h/o fever, abdominal pain, weight loss, decreased appetite (s/o pancreatitis)

6. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
VITAL SIGNS:
BUILT: moderate NUTRITION: moderate BP: 110/70 PR: 80/min
RR: 20/min
GCS: 15/15 ICTERUS: positive
CLINICAL EXAMINATION:
RESP SYS: NVBS(+)
ABDOMINAL SYS:
Soft minimal epigastric tenderness (heart burn),
no rigidity, scratch marks(+)
CVS: S1S2(N)
CNS- no deficits

7. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
LAB REPORTS:
Day Parameter Result Remark
1,2,3,4 Hb 8.9,11.9,13.4,9.8(14-18) Malabsorption,anemia
1,2 TC 11000,10000(4-11000) Normal
1,2 Neutophils 74,52(50-70) Slightly increased
2 Lymphocytes 40(20-40) Normal
1 Plts 2.93lakh(1.5-4.5) Normal
1,2 PT/APTT 15.3,11.31,38.0,43.1(25-
35sec)
Decreased
coagulation protein
1 ESR 48 (0-15mm/hr) anemia
1 PCV 35.3,39.3,29.1(40-45) anemia
1,2,3,4 GRBS 110,138,127,121(70-180) Normal
1,2,3,4
5,6
Creatinine 0.93,0.82,0.88,1.01,1.01 Kidney complication
is ruled out
CONTD….

8. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
LAB REPORTS:
Day Parameter Result Remark
1,2,3,4,5 Na+ 137,131,125,122,128(135-145) Increased Na
excretion(cause of BP)
1,2,3,4,5 K+ 2.9,4.1,4.7,4.6,3.9(3.5-5) Normal
1 TSH 3.94(0.5-4.8mU/L) Thyroid jaundice is
ruledout
1,5,8 Total Bilirubin 5.99,1.99,5.39 (0.2-1,3) Decreased excretion
1,5 Direct Bilirubin 3.32,0.68,3.42 (0-0.3) Billiary tract
obstruction,GB & CN
ruled out, cholestasis
1,5 Total protein 4.37,4.25,32.4(6-9g/dl) erratic
1,5 Albumin 9.26,2.06,43.9 (3.5-5) HYPERALBUMINE
MIA: ASCITIES R/O
1,5 SGOT 211,66 ,51(10-40) Pancreatic injury.
1,5 SGPT 57,41,34(10-40) Liver injury
1,5 ALJ Phosphatase 36,71 ,351 (40-160) Obstruction
CONTD….

9. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
LAB REPORTS:
Day Parameter Result Remark
1 Hiv Negative Hiv as a
cause of OJ is
ruled out
1 HBs Negative No viral
infection
1 HcV negative Hepatits is
ruled out
1,8 Amylase 43,25 (23-85 U/L) Borderline
low on day 8:
metabolic
functtion
MRCP Lesion in ampulla Carcinoma
8 Ca 9.9 (8.4-10.2mg/dl) normal
CONTD….

10. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
MEDICATIONS:
DAY &
TIME
NAME OF MEDICATION
(GENERIC NAME)
DOSE ROUTE TIME INDICATION
1,2 INJ CEFAZOLIN 1gm IV 12a:8a:
4p
Infective
cholangitis
1,2,3,4,5,6 INJ GENTAMYCIN 160mg IV 10am Prophylactic
chemo
1,2,3,4,5,6 INJ METRONIDAZOLE 500mg IV 6-2-10 diarrhoea,oper
ation on Gi
tract
1,2,3,4,5,6 INJ OMEPRAZOLE 40mg IV 6-6 Gi distress
1,2,3,4,5,6 INJ PARACETAMOL
(ACETAMINOPHEN)
1g IV 6-2-10 Fever and pain
1,2,3,4,5,6 INJ
CLEXANE(ENOXAPARIN)
40mg S/C OD Abdominal
surgery-post
operative
DVT:prophylaxi
s
CONTD….

11. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
MEDICATIONS:
DAY & TIME NAME OF MEDICATION
(GENERIC NAME)
DOSE ROUT
E
TIME INDICATION
2,3,4,5,6 INJ
PIPERACILLIN/TAZOBACTA
M
4.5g IV 11-7-3 Infection
2,3,4,5,6 INJ
PETHIDINE(MEPERIDINE)
50mg IM SOS Pain
1,2,3,4,5,6 INJ PHENERGAN
(PROMETHAZINE)
25mg IM SOS To treat allergy
symptoms like
itching
2,3,4,5,6 INJ MAGNEX FORTE
(CEFOPERAZONE+SULBACT
AM)
1.5gm IV 6-2-10 Infection
1,2,3,4,5,6 Inj.PETHIDINE 50mg Iv sos pain
2 Inj. TRAMADOL 50mg IV STAT PAIN
2 INJ. ONDANSETRON 40mg IV STAT CINV & PONV
CONTD….

12. OBJECTIVE EVIDENCEOBJECTIVE EVIDENCE
MEDICATIONS:
DAY & TIME NAME OF MEDICATION
(GENERIC NAME)
DOSE ROUT
E
TIME INDICATION
2,3,4 NEB. DUOLIN & BUDECORT BREATHING
DIFFICULTY
2 NS BOLUS 500ml IV STAT(1
1PM)
HYPONATREMIA
2,3 IVF. DNS @500
ml/hr
NUTRIENTS
SUPPLEMENTS
5,6 Tab. DOMPERIDONE No
time
FJ 7am-
7pm
N & V.
EPIGASTRIC
PAIN
7,8,9,10 INJ. VITAMIN K 10
MG
IV 8PM DEF OF
FATSOLUBLE
VITAMIN.(LFT) &
BLEEDING
7,8,9,10 TAB. LEVOCETRIZINE 5MG P/O 9A-9P ITCHING
CONTD….

13. PROGRESS CHARTPROGRESS CHART
PHYSICIAN/NURSE NOTES:
DAY 1
O/E: BP-118/60 SPO2-96%
P/A: mild distension
PR:130/min
DAY 2
Had fever spikes yesterday
O/E: PR-138 BP-150/80 SPO2-99%
P/A:Soft bowel sounds sluggish
PLAN:CST
DAY 3
1 episode of 100*F fever
O/E:PR-120 SPO2-96%
PLAN: Shift to HDU
DAY 4
H/O fever
PR-124 BP-130/80 SPO2-93%
PLAN:CST
DAY 5
C/O severe abdominal pain
Loose stools
PLAN:USG abdomen
DAY 6
Pt comfortable
Moved bowels
PLAN:CST

14. PHARMACEUTICALPHARMACEUTICAL
CARE PLANCARE PLAN

15. ASSESSMENTASSESSMENT
DIAGNOSIS LIST:
Obstructive jaundice
DIFFERENTIAL DIAGNOSIS:
Periampullary carcinoma

16. ASSESSMENTASSESSMENT
REFERENCES:
DISEASE EVALUATE CURRENT THERAPY FOR
PROBLEM
EVALUATE NEED FOR
THERAPY
Fever ACETAMINOPHEN To reduce the elevated body
temperature and bring back to
normal
PERIAMULLARY
CARCINOMA
WHIPPLES PROCEDURE To remove the tumour cells
from the pancreas
PRURITIS
(ITCHING)
LEVOCETRIZINE To decrease the itching.
Breathing
difficulty
Duolin
Budecort
To faclitate the breathing
process.
CONTD….

17. PLANNINGPLANNING
DISEASE GOALS FOR TREATMENT OF PROBLEM GOALS ACHIEVED (Y/N)
Jaundice •To bring the bilirubin level to normal
level
yes
PERIAMULLARY
CARCINOMA
•To remove the tumour cell Yes
FEVER •To reduce the eleveated body
temperature and bring back to normal
level
Yes
•

18. PLANNINGPLANNING
RECOMMENDATIONS:
REFERENCES:
DRUG
TREATMENT
MONITORING
PARAMETERS
FURTHER TESTS DRUGS TO BE
AVOIDED/WHY
APPRETPITANT
125mg P/O
BLEEDING TIME Lipid profile test
INR
ONDANSETRON:
concurrent use with
metronidazole == qt
prolongation
DEXAMETHASON
E
PCV,CBC Bun, crcl
LDH(raised in hemolysis)
rules out prehepatic
Octreotide
(carcinoid or
metastatic
syndrome)
Urobilinogen
Alpha-1-antitrypsin levels:
deficiency causes cirrhosis and
emphysema.
Dipstick test
ERCP
ECG
biopsy
GGT, NT
CONTD….

19. PLANNINGPLANNING
DISCHARGE MEDICATIONS:
DATE & TIME NAME OF MEDICATION
(GENERIC NAME)
DOSE ROUTE TIME INDICATION
Tab. Levocetrizine 5mg P/o Itching
Tab. Zoncovit p/o suplements
CONTD….

20. CLINICAL PHARMACIST INTERVENTIONCLINICAL PHARMACIST INTERVENTION
DRUG SPECIFIC:
 DOSE of domperidone was not written ( 5mg/10mg).. And the route of its
administration was not clear.(FJ route)
 PIPTAZ,cefazolin and metronidazole are known to cause SJS and TEN, and this pateint
already presented the complaints of prurits and itching(close watch and and
distinguish).
 Increased liver finction test is reported with 5.9% to 6.1% incidence rate. So the
elevated LFT should be distingiushed… whether drug induced of OJ.(clexane)
 Even fever up to 8% incidence rate is reported … patients already have complaints of
fever
 Concurrent use of AMINOGLYCOSIDE and PENICILLIN may result in loss of
aminoglycoside efficacy

21.  Major adverse effects of GENTAMYCIN is nephrotoxicity and ototoxicity.
 When GFR is calculated using cockgroftgault formula it was found to be 69.86ml/min.

22. PATIENT EDUCATIONPATIENT EDUCATION
DISEASE SPECIFIC:
 Jaundiceistheyellow discolouration caused by accumulation of bilirubin in tissue
 Takeadequateamount of fluids.
 Adequaterest and moderateexerciseisbeneficial.
 .Obstructivejaundiceistheresult of ablockagein thetubesthat transport bilebetween
theliver, gallbladder and small intestines

23. DRUG SPECIFIC:
 Take omeprazole half hr before or 2 hrs after food.
 Do not alter or miss the dose of the medication.
 Cefazolin may cause diarrhoea,nausea,vomiting or thrombocytopenia. Consult
physician before taking any antidiarrhoeal.
 Signs and symptoms of ototoxicity and nephrotoxicity should be reported.
 Avoid alcohol==disulfiram reaction (metro and cef).
 Signs and symptoms of the bleeding should be reported. (clexane)
 Patients should avoid concurrent anticoagulant including NSAID and aspirin without
approval.
 Patient should rotate the injection site if selfadminstration of clexane.
 Tablet domperidone should be taken before meal

24. DIET SPECIFIC:
• Increaseintakeof foodsrich in calcium and other mineralslikeiron and magneium
• Vegetablesshould be taken in raw or steamed form,avoid spicy and junk fried foods
• Gooseberry rich in vit c isand papayaleaves useful in alleviating symptomsof jaundice
Squeeze half a lime into a glass of sugarcane juice
and drink twice or thrice daily.
Mix the neem juice(1tbsp) with sugar (2tbsp) in
water (1glass). Drink this liquid every morning)

25. Add a cup of barley to about three liters of water and simmer for
a couple of hours. Drink this frequently during the day for relief
from jaundice.
Add some pepper and salt to fresh tomato juice and drink
every morning. Lycopene from tomatoes can help to reduce
damage to the liver and even facilitate recovery.
Extract the juice from a piece of ginger, combine with
lime juice and mint juice and consume several times
a day.
Dilute lemon juice with water and drink frequently
during the day. This will help in protecting the liver cells.

26. Add a quarter teaspoon of turmeric powder to warm
water and drink twice daily. Grind some tender papaya leaves into a paste. Combine the
paste with half a teaspoon of honey and consume.
Add a pinch of roasted cumin seeds powder and
some salt to buttermilk and consume. This aids in
proper digestion and is beneficial for the liver.
Take baels leaves and grind to make a
powder. Mix it to a glass of water. Drink
this once a day for effective cure of
jaundice.

27. Banana: Crush ripe banana and add some honey and take this at least twice a day for
better results.
JAUNDICE: FOODS TO
Avoid spicy and fried foods.
Avoid junk and carbohydraterich foodsasliver needsto producemorebileto digest these
foodsand that may aggravatethecondition.
Avoid alcohol, coffeeand tea. Drink boiled water and avoid non-pasteurized milk.
Pulsesand legumesshould beavoided.
Bitter gourd and drumsticks are very beneficial for jaundice patients.

28. REFERENCES:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3109817/ ==Hyperthyroidism and
Jaundice
https://www.researchgate.net/publication/51452086_Hyperthyroidism_and_Jau
ndice
https://www.ncbi.nlm.nih.gov/pubmed/21427435
An unusual cause of acute obstructive jaundice in an HIV-infected patient
http://www.findhomeremedy.com/best-home-remedies-for-jaundice/
http://online.lexi.com/
www.medscape.com
Micromedex
http://www.authorstream.com/Presentation/mblokesh-1255493-obstructive-
jaundice/

29. PIL FOR JAUNDICE PATIENTS.pdf
PIL FOR WHIPPLE PROCEDURE.pdf