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•Good and congenial relationship with the neighbours•Has some good and close friend at his place and he actively interact with them. They also very supportive to him•Good social support system is present from the family as well as from the neighborhood3. Developmental factors•Patient confidently says that he had been worked for 32 years as a teacher and he was a very good teacher for students and was a good coworker for the friends.•He told that he could manage the official and house hold activities very well•He was very active after the retirement and once he go back also he will resume the activities 4. Spiritual belief system•Patient is Christian by religion•He believes in got and used to go to church and also an active member in the religious activities.•He has a personal Bible and he used to read it min of 2 times a day and also whenever he is worried or tensed he used to pray or read Bible.•He has a good social support system present which helps him to keep his mind active.INTERPERSONAL FACTORS•has supportive family and friends •good social interaction with others•good social support system is present•active in the agricultural works at home after the retirement•active in the religious activities.•Good interpersonal relationship with wife and the children•Good social adjustment presentEXTRAPERSONAL FACTORS•All the health care facilities are present at his place•All communication facilities, travel and transport facilities etc are present at his own place.•His house at a village which is not much far from the city and the facilities are available at the place.
•Financially they are stable and are able to meet the treatment expenses.Summary •Physiological- thin body built pallor of extremities, yellowish discoloration of the mucus membrane and sclera of eye. Nausea, vomiting, reduced appetite, reduced urinary out put. Diagnosed to have periampullary carcinoma.•Psycho socio cultural factors- patient is anxious abut his condition. Depressive mood. Not interacting much with others. Good support system is present. •Developmental –no developmental abnormalities. Appropriate to the age.•Spiritual- patient’s belief system has a positive contribution to his recovery and adjustment.CLINICAL FEATURES•pain abdomen since 4 days•Discoloration of urine•Complaints of vomiting•Fatigue•Reduced appetite•on and off fever•Yellowish discoloration of eye, palms and nails•Complaints of weight loss•Edema over the left legINVESTIGATIONSInvestigationsValuesHemoglobin(13-19g/dl)6.9HCT (40-50%)21.9WBC (4000-11000 cells/cumm)12200Neutrophil(40-75%)77.2Lymphocyte (25-45%)10.5Monocyte (2-10%)4.5
Eosinophil(0-10%)2.6Basophil (0-2%).2Platelet (150000-400000 cells/cumm)345000ESR (0-10mm/hr)86RBS(60-150 mg/dl)148Pus C/S_USGUSG shows mild diffuse cell growth at the Ampulla of Vater which suggests peri ampullary carcinoma of Grade I with out metastasis and gross spread.