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PE23.1-21 | Gastrointestinal and Hepatobiliary System — Assignment

CLINICAL SCENARIO

You will write a structured clinical case analysis of a child presenting with jaundice and hepatosplenomegaly. This mirrors real paediatric clinical encounters where you must integrate history, physical examination, investigations, and management planning for GI and hepatobiliary disorders. The ability to construct a logical clinical narrative that moves from presentation to diagnosis to management is a core CBME competency for final-year students.

Instructions

Using the clinical scenario provided below, write a structured case analysis of 800–1200 words. You may use the actual clinical information from your ward or OPD, OR write based on the fictional vignette provided.

Clinical vignette (if using fictional case): Rajan, a 10-year-old boy, is brought to the paediatric OPD with a 3-month history of abdominal swelling, easy fatigability, and two episodes of vomiting blood. His parents recall he had a serious neonatal infection requiring hospitalisation and umbilical catheterisation. On examination: alert, afebrile, mild pallor, no jaundice, no spider angioma or palmar erythema; abdomen shows splenomegaly (5 cm below left costal margin), no hepatomegaly, no ascites. LFTs are normal. Ultrasound Doppler reports cavernomatous transformation of the portal vein.

Structure your write-up using the required sections below. Use evidence-based reasoning at every step.

Length: 800–1200 words (excluding references). Clinical examination findings and investigation tables may be presented as formatted lists within the word count.

What to Submit

1. History and Clinical Presentation

Guidance: Summarise the relevant history: onset, duration, associated symptoms (jaundice, oedema, bleeding, weight loss), risk factors (neonatal history, family history of liver disease, drug exposure, dietary history). Note all positive and negative history pertaining to GI and liver disease. Reference PE23.17 competency: eliciting a complete GI-focused paediatric history.

2. External Markers and Physical Examination

Guidance: Describe the external markers of GI/liver disease you looked for (jaundice, pallor, clubbing, leukonychia, spider angiomata, palmar erythema, gynecomastia, caput medusae, xanthomas, ichthyosis). Document abdominal examination: organomegaly method (percussion + palpation), ascites (shifting dullness, fluid thrill), and any other relevant findings. Reference PE23.18 and PE23.19.

3. Differential Diagnosis

Guidance: List at least 3 differential diagnoses for hepatosplenomegaly in a child, explaining the clinical features that support or refute each. At minimum, address: (a) portal hypertension (EHPVO vs cirrhosis), (b) chronic liver disease, (c) haematological causes (thalassaemia, leukaemia). Reference PE23.15 and PE23.16.

4. Investigation Plan and Interpretation

Guidance: Choose and justify key investigations. You MUST include: LFTs and how to interpret them (hepatocellular vs cholestatic pattern), viral hepatitis markers (which to order and why), abdominal Doppler ultrasound (what to look for), and any other relevant tests. Interpret the findings in the context of the most likely diagnosis. Reference PE23.20, PE23.13, PE23.15.

5. Diagnosis and Pathophysiological Basis

Guidance: State your final diagnosis with reasoning. For EHPVO: explain the pathophysiology (portal vein thrombosis → cavernous transformation → portal hypertension → varices/splenomegaly). For chronic liver disease: explain how hepatocyte dysfunction leads to hypoalbuminaemia, coagulopathy, and portal hypertension. Reference PE23.15, PE23.16.

6. Management Plan

Guidance: Write a structured management plan addressing: (a) acute variceal haemorrhage management (vasoactive drugs, EVL, antibiotics); (b) prevention of rebleeding (beta-blockers, EVL programme); (c) nutritional management in chronic liver disease; (d) monitoring plan (LFTs, endoscopy, growth). If Wilson disease or chronic viral hepatitis is the cause, include specific therapy. Reference PE23.14, PE23.15, PE23.16.

7. Reflection and Counselling Points

Guidance: Reflect on: (a) what information you would give to the family about the diagnosis and prognosis; (b) what this case taught you about recognising GI/hepatobiliary disease in children; (c) one clinical skill you need to develop further (e.g., correct technique for assessing shifting dullness, interpreting LFTs). This section demonstrates metacognitive awareness.

Grading Rubric — Gastrointestinal and Hepatobiliary Case Write-up Rubric

Criterion	Points	Full-marks descriptor
History and Clinical Examination Quality (completeness, GI-focus, external markers documented)	20 pts	Complete, systematic history including all GI risk factors; all relevant external markers documented; abdominal examination described accurately (organomegaly characterisation, ascites assessment).
Differential Diagnosis — Reasoning and Accuracy	20 pts	≥3 relevant differentials; each supported by clear clinical reasoning; EHPVO vs cirrhosis distinction correctly articulated; haematological cause included.
Investigation Selection, Justification, and Interpretation	20 pts	Correct investigation panel chosen; LFTs interpreted as hepatocellular vs cholestatic pattern; viral markers ordered with justification; Doppler USG interpretation stated; findings linked to diagnosis.
Diagnosis, Pathophysiology, and Management Plan	25 pts	Correct diagnosis with evidence-based pathophysiological explanation; management plan comprehensive (acute bleeding, prophylaxis, nutrition, monitoring); disease-specific treatment (Wilson/viral hepatitis) addressed where applicable.
Reflection, Counselling Points, and Academic Presentation	15 pts	Thoughtful reflection on learning; specific, empathetic counselling points for family; identifies a concrete skill gap; well-structured writing within word guidance; references cited.

PEER REVIEW

Review your peer's case write-up using the rubric above. For each criterion, assign a score and write 2–3 sentences explaining your rating. Focus your feedback on: (1) whether the EHPVO vs cirrhotic portal hypertension distinction was correctly made and explained; (2) whether the investigation interpretation was clinically logical; (3) one specific suggestion to improve the management plan. Be constructive and specific — avoid generic praise or criticism.