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CASE

PRESENTATION 7
SITI NUR BAITI BINTI SHAIK
KHAMARUDIN
012013100196

PATIENTS IDENTIFICATION

Name : Norziza
Age : 31
Gender : Female
Race : Malay
Religion : Islam
Address : Bandar Parkland, Bukit Tinggi, Klang
Occupation : Housewife
Marrital status : Married with 2 children
Date of admission: 31/10/2015
Date of clerking : 1/11/2015
Informant : Patient
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CHIEF COMPLAINT

Right upper quadrant abdominal pain


for 3 days prior to admission.

Patient started
have pain at hypochondriac
HISTORY
OF toPRESENTING
ILLNESS

region 2 days before she was admitted to HTAR.


The pain was continuous and sometimes it got

worsen.

Pain is non-radiating.

Pain is colicky in nature.

It was aggravated when the patient moved and


after she ate.
The pain is relieved if she lied down or leaned

forward.
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Patient claimed that she has 2 episodes of vomiting 1


day prior to admission and the vomitus contained food
particles.

She also experienced a low-grade fever and loss of


appetite.

Nothing abnormal detected in her stool and urine.

She denied having symptoms such as headache,


diarrhoea, constipation, urine disturbance and
breathing problem.

No loss of weight.
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Menstrual History

First menarche: 13 years old.

Pattern of menstruation: Irregular

No complaint of dysmenorrhea.

SYSTEMIC REVIEW
Cardiovascular system
Respiratory system

Genitourinary system

Neurological
system
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She has no chest pain


and no palpitation.
She has no shortness
of breath, no cough, no
dyspnoea.
She has no frequency,
no dysuria, no
hesitancy, no
incontinence or
nocturia.
He has no headache,
no visual disturbance
or speech

PAST MEDICAL HISTORY

Never undergo any surgery.

Never been warded.

Not under any prescription medication.

No drug allergies.

SOCIAL HISTORY

She has 2 children whom she gave birth under


normal delivery.

Financially supported by her husband.

Patient claimed she has been taking oral


contraceptive pills (OCP) ever since she gave
birth to her first child.

Does not smoke and never smoke.

No history of drug abuse and alcohol intake.

FAMILY HISTORY

Family has no history of malignancy and other


medical illness like DM and MI.
Both her parents and her siblings are alive
and healthy.

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PHYSICAL EXAMINATION
General Examination

Alert, conscious, pink and hydrated.

Lying comfortably in supine position.

Patient was on Normal Saline intravenous drip


attached to dorsum of her left hand.

ID tag on left arm.

Not in respiratory distress.


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Vital Signs

Pulse rate

Breathing rate

Body temperature: 38.1oC

Blood pressure : 125/76 mmHg

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: 84 beats/min
: 20 breaths/min

Hand Examination

The hands were warm and moist.

No flapping tremor.

Capillary filling time is normal (<2 seconds)

No clubbing.

No peripheral cyanosis.

No koilinychia.

No tobacco stain.

No palmar erythema.
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Head and Neck Examination

Eye: No conjunctival pallor.


Presence of mild sclerotic jaundice.
Mouth: Oral hygiene is satisfactory
No central cyanosis
No angular stomatitis
Neck: No lymphadenopathy

Lower Limb Examination

No indentation.
No pitting oedema.

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ABDOMINAL EXAMINATION
Inspection

The abdomen is scaphoid, symmetry and


moves with respiration.

The umbilicus is centrally located and


inverted.

No surgical scars.

No prominent dilated veins.

No supraclavicular lymph node enlargement.

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Palpation

There is tenderness at right hypochondriac


region upon superficial and deep palpation.

No guarding and rebound tenderness.

No palpable mass.

The liver is not palpable.

No splenomegaly.

Murphys sign is positive.

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Percussion

No shifting dullness and fluid thrill.

Auscultation

Bowel sounds was present with normal


intensity.

No renal bruits heard.

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SUMMARY
A 31 year-old housewife came to HTAR with a chief
complaint of abdominal right upper quadrant pain for 3
days associated with vomiting, low-grade fever and loss
of weight.
The pain was continuous and colicky in nature but
non-radiating.
On physical examination, she was pyretic. There was a
mild sclerotic jaundice and tenderness at hypochondrium
with no other abnormal findings upon abdominal
examination.
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ZAWIN NAJAH BT RAHIM


012013100234

PROVISIONAL DIAGNOSIS
Ascending Cholangitis

Jaundice
Fever
Right Upper Quadrant pain
Intake of oral contraceptive pill that is
later replace with contraceptive injection
Dilatation of bile duct
Leukocytosis

DIFFERENTIAL DIAGNOSIS
DISEASES
ACUTE
PANCREATITIS

SUPPORTING
POINTS
Present of fever,
right upper
quadrant pain

ACUTE
Present of fever,
CHOLECYSTITIS
right upper
quadrant pain

POINTS
AGAINST
No jaundice,
increase serum
amylase
Positive
Murphys sign

DISEASES
HEPATITIS

LIVER ABSCESS

SUPPORTING
POINTS
Right upper
quadrant pain,
jaundice
Right upper
quadrant
pain,jaundice,
fever

POINTS
AGAINST
No fever

No gallstone, no
bile duct
dilatation

INVESTIGATION

Full Blood Count


Serum Amylase Level
Liver Function Test
Renal Profile
Transabdominal ultrasound

Full Blood Count


Test

Result

Unit

Range

Haemoglobin

14.7

g/dL

8.0-17.0

RBC

4.93

10^6/L

2.5-5.5

WBC

16.53

10^3/L

3.015.0

Haematocrit

41.3

26.0-50.0

MCV

83.8

fL

86.0-110.0

MCH

29.8

pg

26.0-38.0

MCHC

35.6

g/dL

31.0-37.0

RDW

47.2

11.0-16.0

Platelet

529

10^3/L

50-400

MPV

10.5

fL

9.0-13.0

Neutrophil %

13.4

40-80

Lymphocytes %

2.03

20-40

Monocytes %

1.00

2-10

Eosinophils %

0.06

1-6

Basophils %

0.04

< 1-2

Renal Profile
Test

Result

Unit

Range

Urea

3.6

mmol/L

2.8-7.2

Sodium

141

mmol/L

136-145

Potassium

4.3

mmol/L

3.5-5.1

Chloride

100

mmol/L

98-107

72

mmol/L

59-104

Creatinine

Liver Function Test


Test

Result

Unit

Range

Albumin

51

g/L

35-52

Globulin

32

g/L

25-39

A/G ratio

83

0.9-1.8

ALP

221

IU/L

30-120

ALT

423

IU/L

0-50

132.0

mmol/L

5-21

Total bilirubin

Transabdominal ultrasound
LIVER
Normal parenchymal echogenicity with
normal focal lesion.
Smooth liver margin
Liver is normal in size (15.2 cm)

GALLBLADDER

Well distended with thickened wall (0.8 cm)


No gallbladder calculus
No pericholecystic fluid
No tenderness elicited

DUCTS
Right and left intrahepatic duct and
common bile duct are mildly dilated.
Mild dilatation of common bile duct
No obvious calculus at the distal
common bile duct
No mass seen at the porta
hepatis/pancreatic head region
Portal vein is within normal caliber
Pancreas is normal and homogenous in
echogenicity
Spleen is not enlarged
No free fluid

Serum Amylase
89 U/L

n: 40- 140 U/L

HOSPITAL MANAGEMENT

NBM with IVD


IV Flagyl 50 mg TDS
IV Cefobid 2g BD
IV Pantoprazole 40mg BD
IV Tramal 50 mg TDS

DISCUSSION

ANATOMY: HEPATOBILIARY
SYSTEM

Gall bladder
Pear shaped structure
7.5-12 cm long
25-30 ml
Fundus, body and neck

Cystic duct
3cm ( may be variable)
1-3mm diameter
Calots triangle : cystic duct ( inferior),
common hepatic artery (medial), cystic
artery ( superior)

Bile duct
Right + Left hepatic duct common
hepatic duct
Cystic duct + Common hepatic duct
Common bile duct
Common bile duct emerge with
pancreatic duct just before entering the
duodenum
Bile duct sphincter smooth muscle
surrounding the distal end of the duct

ASCENDING CHOLANGITIS
Ascending bacterial infection of
biliary tract in association with partial
or complete obstruction of bile duct.

EPIDEMIOLOGY
Equal in both gender
Mostly in adults with median age at
onset 50-60 years

ETIOLOGY
Gallstone ( most common cause)
Biliary tract intervention/ and stents,
stricture, tumors, choledochal/biliary
cyst

CLINICAL FEATURES
CHARCOT TRIAD
Fever
Right upper quadrant pain
Jaundice

REYNOLDS PENTAD (progression of


illness)
Septicemia
Mental status change

INVESTIGATION
1.
2.
3.
4.

Full blood count


Liver function test
Blood culture
Transabdominal ultrasound

MANAGEMENT
Broad spectrum intravenous
antibiotic
Fluid resuscitation and correction of
electrolyte imbalance
Treat cholangitis first before
operative therapy
The obstructed bile duct must be
drained as soon as the patient has
been stabilized
Emergency biliary decompression if

COMPLICATION
Pyogenic liver abscess
Acute renal failure