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CASE WRITE UP

SURGICAL POSTING

NAME : SANGARI A/P SARKUNA


SINGAM
STUDENT ID : 1001439079
GROUP 3
HISTORY TAKING

Patient's Information

Name : Suhaini Binti Mohamed


Registration number : HSNZ00260799
Age : 47 years old
Gender: Female
Race: Malay
Religion : Islam
Marital Status : Married
Address: Bukit payung, Kuala Terengganu.
Occupation : Teacher
Date of admission : 22/2/2015
Date of clerking: 23/2/2015

Chief Complaint

Patient came in with a complaint of upper abdominal pain 9 hours prior to admission.

History of presenting illness

Patient is a diabetic with a risk factor of being overweight( BMI : 34.4), takes a high calorie
diet which consist mainly of fatty and oily foods and has been taking oral contraceptives pills
for almost 7 years. Her history dates back to June last year when she first felt pain over her
epigastric region. It gradually developed and was dull in nature. The pain then became
constant and persistent and could last for a few hours. The pain radiated to the right
hypochondriac region and her right shoulder blade. The pain frequently got worse at night
and woke the patient. She gave a score of 7 for the pain intensity. She claimed food intake
sometimes aggravated the pain and the pain has no relation to her menstrual cycle. She tried
relieving the pain by putting ointment but the pain did not subside. There was nausea,
indigestion and loss of appetite. However, there were no fever, chills or rigors and weight
loss.

She then went to Klinik Kesihatan Bukit Payung and there they gave her charcoal medication
to enable flatus but that did not help to stop the pain. She then went to HSNZ where they did
an abdominal ultrasound and found that she had an inflamed gallbladder. Patient was treated
with medications though she could not remember the name of the drugs they gave her. The
pain finally subsided and she was discharged well after 3 days stay in the hospital. She was
asked to come for an endoscopic ultrasound at the end of the month and the patient claimed
that the results were normal. After that episode, the pain subsided until last week when she
had a similar pain over the same area ( epigastric region) and again she had nausea and
indigestion. There were no fever, chills and rigors. She then went to the emergency
department in HSNZ where they gave her medications for her cholecystitis in the hospital and
discharged her on the same day with antibiotics which she did not go and collect as she had
misinterpreted and was not aware that she had drugs to be taken at home. The pain declined
but reoccurred again two days ago while she sleeping at night. The pain started at 2am in the
morning and was unable to sleep. She claimed that the pain is similar to the first episode. It
was gradual on onset, dull in nature, radiated to her right hypochondriac region and right
shoulder. However, this time the pain has increased in intensity and persisted longer with a
score of 8 out of 10 for the intensity. She claimed that she did not do anything to relieve the
pain and went straight to the hospital ( HSNZ) the next morning at 11am and was admitted in
ward 2CD.

The patient had jaudice but no pruritus, tea-coloured urine or pale coloured stools. There was
no abnormal urinary symptoms and her bowel function was normal. She did not experience
any abnormal gynaecological symptoms like dysmenorrhea, menorrhagia or intermenstrual
bleeding.

Systemic Review

Cardiovascular system : No palpitation, no chest pain, no orthopnea, no paroxysmal dyspnea,


no ankle edema

Respiratory system : No shortness of breath, No coryzal symptoms, No cough, No


hemoptysis

Gastrointestinal system : Presence of indigestion and nausea, No vomiting,constipation or


diarrhea

Urinary system : No urinary frequency, , no urgency, no dysuria, no hesitancy, no poor


stream of urine, No hematuria

Nervous system: No headache, no fainting attacks, no blurring of vision, no weakness or


numbness of the extremities, no seizures

Musculoskeletal system : Presence of back pain( at her shoulder blade) No bone pain, No
joint pain.
History of past medical and surgical illness

Patient is a known case of diabetes. Other than that, she has no other chronic illness like
hypertension, heart disease, asthma, hepatitis, TB or autoimmune diseases. This patient has
gone for endoscopic retrograde cholangiopancreatography last year in June and did not have
any complications. She also has never been involved in any accidents.

Menstrual and gynaecological history

She achieved menarche at the age of 12. Her menstrual flow is usually for 4 to 5 days out of
the 30 days cycle and is regular. During menstruation she uses about 5 pads, fully soaked for
the first 3 days and about 4 pads for the remaining days. Her last menstrual period was on the
20th of january last month. The patient has no experience of gynaecological problems.

Obstetric History

She has 5 children and all are alive and well. Her first child, a boy is now 18 years old and
her last child who is also a boy is now 8 years old.

Drug and allergy history

Patient is on metformin for her diabetes. She started taking oral contraceptive pills after her
last child and is has been almost 7 years since she has been taking it. Other than that, she
claims she did not take any other over the counter drugs, vitamins or herbal remedies. She has
no known drug or food allergy.

Family History

Her parents are both alive. Her mother has diabetes whereas her father is well. Besides that,
there are no other medical illness such as hypertension, heart disease, renal diseases or
tuberculosis in her family. Her other five siblings are all fine. There is no history of
malignancy or inherited disease.

Social History

The patient does not smoke, drink alcohol or take intravenous drugs. She has been married
for 21 years and her husband is a businessman and he is a smoker. She is currently staying
with her husband and 5 children in a teres house with all the necessary amenities. Both her
husband and her salary is enough to sustain their cost of living.

PHYSICAL EXAMINATION

General examination
The patient was comfortably lying supine on the bed with one pillow under her head. She was
alert, conscious and responsive. She does not appear to be in pain or respiratory distress.
There was no sign of pallor, jaudice, cyanosis or odema. The patient appeared to have good
nutritional and hydration status. There was a canula on her right hand.

Vital signs
Respiratory rate: 20 breaths/min (normal)
Pulse rate: 82 beats/min (normal volume and regular rhythm, collapsing pulse not present)
Temperature: 37 C
Blood pressure: 120/70 mmHg (normal)
Pain score: 0 out of 10

On examination of the hands, her hands were warm and dry. There were no signs of
koilonychia, leukonychia, clubbing, palmar erythema, dupuytren's contracture, hepatic flap
sign or peripheral cyanosis. Capillary refill time was less than 2 seconds.
On examination of the face, her conjunctiva was pink and her sclera was yellow. There were
no signs of corneal alcus, xanthelasma and kayser's-fleisher rings in the eyes. The mucous
membrane of the oral cavity was moist and no central cyanosis, glossitis or angular
stomatitis. As for the examination of the neck, no thyroid or lymph nodes mass were palpable
and jugular venous pressure was also not raised. On examination of the lower limbs, there
was no pedal edema at her legs, calf tenderness was not present and no varicose veins seen.

On cardiovascular examination, first and second heart sounds (s1 and s2) were heard, apex is
located at the 5th intercostals space midclavicular line,no heaving, thrills or thrusting felt .No
murmurs or other abnormalities detected.

For respiratory examination, patient had the normal vesicular breath sounds, air entry was
equal on both sides with no added sounds such as crackles and no sign of pleuaral effusion.
Upon percussion there was no difference on both signs. Vocal fremitus and vocal resonance
are equal on both sides.

Nervous system intact.

Abdominal examination
Upon inspection, the abdominal wall moves symmetrically with respiration and the umbilicus
is centrally located and inverted. The abdomen was distended but there were no striae, no
spider nevi, dilated veins or surgical scars evident. No visible pulsation and peristalsis was
seen. There was no discoloration around the umbilicus (cullen's sign) and Turner's sign is
negative in this case. There was also no inguinal hernia seen when the patient is asked to
cough.

On superficial palpation, the abdomen was soft and non-tender. On deep palpation, there was
tenderness at the right upper quadrant and the liver was enlarged by 2cm below the subcostal
margin. There were no splenomegaly and the kidneys were not ballotable. Murphy sign was
negative. On percussion, there were no shifting dullness. On auscultation, normal bowel
sound was heard and no bruits could be heard.
Per rectal and external genitalia examination was not done for this patient. Supraclavicular
lymph node examination was performed and there were no palpable lymph node
enlargement.

Summary
Puan Suhaimi, 47 years old malay lady with a history of cholecystitis with risk factors like
being overweight, taking high calorie diet and taking oral contraceptive pills came in with a
complaint of epigastric pain, dull in nature radiating to the right hypochondriac region and
right shoulder blade. She has nausea, loss of appetite, indigestion and was intolerable to fatty
food. On physical examination, her sclera was yellowish and there was tenderness at the right
upper quadrant and her liver was enlarged.

Provisional Diagnosis
Puan Suhaimi who is 47 years old is admitted to the surgical ward for acute cholecystitis.

Supporting points

- Patient is in her forties( 47 years old)

- Obese ( BMI : 34.4)

- Takes high calorie diet

- Taking oral contraceptive pills for almost 7 years.

- Nausea

- Loss of appetite

- Indigestion

- Intolerable to fatty food

- Jaudice

- Tenderness at the right upper quadrant

- Liver was enlarged.

Differential diagnosis
1) Appendicitis
Point against- No migratory pain from the umbilicus to the right illiac fossa, abdominal
swelling or constipation.

2)Urolithiasis

Points against- Absence of urinary symptoms , flank or loin pain.

3) Perforated peptic ulcer

Points against - Absence of bloody and dark tarry stools, weight loss and hematemesis. No
abdominal rigidity and abdomen wall movement is not restricted.

4) Pancreatitis

Points against- No fever, weight loss or stearrhoea.

5) Pelvic inflammatory disease

Points against :- absence of bilateral pelvic pain, dysuria and vaginal discharge

6) Pyelonephritis

- No fever, flank pain and abnormal urinary symptoms.

7) Ectopic pregnancy

Points against :- absence of per vaginal bleeding

8) Torsion or rupture of ovarian cyst

- No abdominal swelling and pain is not related to menstrual cycle.

9) Myocardial infarction ( as referred pain) and pneumonia.

Investigations

Laboratory :

a) Full blood count is done to detect anaemia and rule out any infections.

b) BUSE is done as a baseline investigation and to detect any electrolyte imbalance.

c) Urinalysis helps to rule out conditions like urinary tract infection or a kidney stone, which
can cause abdominal pain. If it is a kidney stone, red blood cells are usually seen during
microscopic examination of the urine.

d) Liver function test - to test for any abnormalities in the liver.


e)Serum amylase level - To rule out pancreatitis.

Imaging studies :

e) Abdominal X-Rays - To detect gallstones and calcification of the gall bladder. Also rule
out other causes of acute abdomen.

f) Ultrasonography - To detect biliary calculi and dilation, thickened gall bladder and also to
demonstrate presence of inflammation around the gall bladder.

g) Abdominal and pelvic CT scan - Used when the diagnosis is uncertain.


h) Magnetic resonance cholangiopancreatography- to detect ductal obstruction, strictures or
other intraductal abnormalities
i) Endoscopic retrograde cholangiopancreatography- used as diagnostic and therapeutic
modality.
j) Percutaneus transhepatic cholangiography- to detect strictures and obstructions.

Management

Conservative treatment :

1) Withhold oral food and fluids from patient ( fasting) - To not stress the inflamed gall
bladder.
2) Intravenous fluid administration
3) Analgesics- to relieve pain
4) Antibiotics- given as prophylaxis.
5) Plan for delayed cholecystectomy after 6 weeks or interval cholecystectomy done ( if the
pain and tenderness increase despite giving conservative treatment)

Definitive treatment :
1) Open or laprascopic cholecystectomy