Good evening.

I would like to share the case that we discussed today during BST with
Prof.Annal this afternoon.Here’s the summary of the case.

Mr M.M ,a 64 y/o indian Muslim man,with underlying

1.BPH(not on medication)
2.Newly diagnosed diabetes mellitus (on insulin)
3. *Bladder calculi diagnosed in 2015 *

Referred from Hospital Rembau with complaints of:

1.left groin pain for 4 days
-worsening and increasing intensity
-non-radiating
-sharp in nature
-unable to sleep at night
- associated with 3 episodes of vomiting

2.dysuria for 2 days

-present on and off for past 3months
-worsening over time
-did not seek any medical attention

3.Hematuria for 3 days

-3 episodes
-painful terminal hematuria

Of note, he developed fever and chills on the 1st day of admission in the ward and resolved
within a day..For the past 1 year, patient complains of nocturia ,which wakes him up 2-3
times per night and increased in urinary frequency.Otherwise ,denies symptoms such as
urgency,dribbling,hesitancy,weak stream and intermittency.He has reduced in appetite for
the past 1 year but no loss of weight .Patient is ex-smoker of 40 pack years and

On physical examination, the patient has tenderness over the left lumbar and his bladder
does not feel distended on palpation.
Mrs S, a 39 y/o Malay lady with underlying chronic RUQ abdominal pain, presented to the
ED of HTJS 3 days ago with sudden onset worsening RUQ pain which was 8/10 in severity,
sharp in nature, radiating to the back and shoulder tip, exacerbated by sitting up and relieved
by analgesics. The pain was also associated with non-bilious vomiting, tea-coloured urine
and pale stools for 1 day, jaundice for a week and pruritus for two weeks.

There was no history of fever, pain worsened or relieved by food, malaena, haematemesis,
burning abdominal pain which worsens on leaning forward, history of risky behaviour,
diagnosis of hepatitis, periumbilical pain radiating to the RIF. The patient is not currently
pregnant, does not complain of foul-smelling vaginal discharge, and has never been
diagnosed with PCOS. Urinary symptoms are absent.

For the past month, she had been having constant RUQ which was 5/10 in severity. The
pain caused her to seek the GP who prescribed her with oral and intramuscular analgesia.
No other active management was undertaken.

She was seen in ward 5A, and was scheduled to undergo an ERCP this afternoon.

The discussion revolved around formulating a differential diagnosis for this presentation,
investigating and managing a patient with obstructive jaundice. We also discussed with
difference betweem ERCP and MRCP, how to prepare a patient for ERCP, management of
obstructive jaundice due to periampullary tumours, the differential diagnosis of an
appendicular mass and their respective managements.