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CASE PRESENTATION

MAGESWARY NADARAJAH
012012100053

PATIENTS IDENTIFICATION

Name : Mazura Bt Bahadun

Date of Birth : 16.03.1979

Age : 36 years old

Gende r: Female

Religion : Islam

Race : Muslim

Address : Kampung Sungai Udang, Klang

Occupation : Housewife

Marital status : Married

Registration Number : 1557634

Bed number : 12

Ward number : 3A

Date of Admission : 5th July 2015

Date of clerking : 6th July 2015

Informant : Patient

CHIEF COMPLAINT
Abdominal pain for 3 days

HISTORY OF PRESENTING ILLNESS


presented with complaint of abdominal pain for 3 days
prior to admission which worsen 1 day before admission
sudden onset
right hypochondrium (colicky in nature).
Radiated-back
lasted for 15min
+ doing house chores & relieved by taking painkiller
Pain score : 8/10.

associated - yellowish discoloration of the


sclera( sudden onset & progressive. )
Patient noticed tea coloured urine 2 days prior to
admission.
no hematuria, dysuria, pale stool & pruritus

08/04/15

Intermittent fever - 2 days (relieved by PCM)


no weight loss but reduced appetite

08/04/15

PAST MEDICAL HISTORY


Acute Cholecystitis (diagnosed in April 2015 @ HTAR)
no other medical illness

PAST SURGICAL HISTORY


LSCS was done on 2007 due to fetal distress at HKL.

DRUG AND ALLERGY HISTORY


No any medications, supplements, over the counter
medications and traditional medications.
NKFDA

PERSONAL AND SOCIAL HISTORY


housewife.
lives with her husband & 3 children in an apartment.
Non smoker & non alcoholic

FAMILY HISTORY
No significant family history

CASE PRESENTATION
KAUSALIYA NAIDU
012012050315

PHYSICAL
EXAMINATION
lying in a supine position with one pillow.
alert,conscious, cooperative and well oriented.
not in any distress.
hydration & nutrition status was adequate.
An indwelling catheter attached to a drainage bagcollection of tea coloured urine .
IV branula - dorsum of the left hand

ID tag - right wrist.

VITAL SIGNS
BP - 130/80 mmHg (Normal)
PR - 62 beats per minute (regular rhythm, good
volume)
RR - 15 breaths per minute (Normal)
Temp 37.5 C
SpO2 100%

GENERAL
EXAMINATION
1) Hands

- warm and dry


- no pallor, jaundice, peripheral cyanosis and
palmar erythema
- no clubbing of the nails
- no leukonychia and koilonychia
- CRT : < 2 seconds
- no tattoo, tobacco stain, axilla hair loss and scar
2) Face
a) Eyes - Jaundice - sclera
No conjunctival pallor
b) Oral cavity - No central cyanosis, pallor, oral
mucosa
appeared jaundice
- Oral hygiene was good

3) Neck
- No thyroid& LN enlargement
4) Lower limbs
- No pitting edema

LOCAL EXAMINATION
INSPECTION :
not distended and moves symmetrically with
respiration
Umbilicus- centrally located and inverted
Presence of LSCS scar
-ve Grey turners &Cullens sign
No distended vein, visible peristalsis, visible
pulsation, local swelling, guarding

PALPATION :
Superficially, tender in the right hypochondriac
region.
For deep palpation, the liver was not palpable
Spleen was not palpable and the kidneys were not
ballotable.
Murphys sign -ve

PERCUSSION :
No shifting dullness and fluid thrills present.
Liver span was 9 cm

AUSCULTATION:
Normal bowel sounds.(2/10 seconds)

SUMMARY
36 years old Malay lady presented with abdominal
pain (colicky in nature)
right hypochondriac region - radiating to the
back,
associated with intermittent fever, tea coloured
urine & yellowish discoloration of the sclera
history of acute cholecystitis.
no pale stools, difficulties in flushing and pruritus.
On PE : appeared mild jaundiced with tenderness
in the right hypochondriac region

ANATOMICAL AND
PATHOLOGICAL
Anatomical correlation
Pathological
CORRELATION
correlation
Gall bladder

inflammation
infection
obstruction

Pancreas

inflammation
obstruction
malignancy

DIAGNOSIS
PROVISIONAL DIAGNOSIS
Ascending Cholangitis 2 Acute Cholecystitis
Points to support:
1.History of acute cholecystitis.
2.Right upper quadrant abdominal pain radiating to the back
3.Intermittent fever
4.Tea coloured urine
5.Sclera appeared jaundice.

DIFFERENTIAL DIAGNOSIS
Recurrent Acute Cholecystitis
Points to support:
1.History of acute cholecystitis.
2.Right upper quadrant abdominal pain
3.Intermittent fever
Point against:
1.-ve Murphys sign

Acute Pancreatitis
Points to support:

Points against:

1.History of acute
cholecystitis.

1. Fever was intermittent

2.Tea coloured urine


3.Right upper quadrant
abdominal pain

2.Abdomen was not


distended
3.Normal bowel sounds
4.-ve Cullens and Grey
Turner signs

Pancreatic Carcinoma
Supporting points-Tea coloured urine

-Sclera appeared jaundice.


- Right upper quadrant abdominal pain
Points against

no weight loss
- no family history of pancreatic cancer
- no diabetes mellitus,smoking,alcohol
- no steatorrhea

intake

CASE PRESENTATION
THIPA MAILVAHANAM
012012050310

INVESTIGATIONS
SELF REVIEW

HOSPITAL

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

1. Full blood count

Full blood count


Liver function test
Renal profile
Coagulation profile
Serum amylase
Blood Culture and sensitivity
Hepatobiliary system ultrasonography
MRCP
ERCP
Ct scan

2. Liver function test


3. Renal profile
4. Serum amylase
5. Viral screening
6. Lipid profile
7. Hepatobiliary system ultrasonography
8. ERCP
9. Ct scan
08/04/15

RESULTS
FULL BLOOD COUNT
Value

Unit

11.6

g/dL

Total White Blood Cell

11.7

10^9/L

Hematocrit

34.7

Platelet

324

10^9/L

Haemoglobin

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LIVER FUNCTION TEST


Value

Unit

Normal Range

Total protein

82

G/L

64-83

Albumin

36

G/L

34-50

Globulin

46

G/L

25-39

Alkaline
phosphatase
(ALP)

290

IU/L

40-130

Alanine
aminotransferase
(ALT)

203

IU/L

0-41

Total bilirubin

60.9

mol/L

<17.1

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RENAL FUNCTION TEST


Value

Unit

Normal Value

Urea

0.9

mmol/L

2.5-6.4

Sodium

133

mmol/L

136-145

Potassium

3.4

mmol/L

3.5-5.1

Chloride

99

mmol/L

98-107

Creatinine

57

mol/L

62-106

SERUM AMYLASE

Amylase

Value

Unit

Normal Range

40

IU/L

28-100

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Hepatobiliary system ultrasonography and liver plain CT scan


- choledocholithiasis, cholelithiasis & cystic duct lithiasis =
biliary obstruction.
Evidence of cholecystitis with cholangitis sonographically.

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MANAGEMENT
SELF REVIEW

HOSPITAL

1. Broad spectrum antibiotic

1. IV Cefobid 2g BD

2. Nil by mouth

2. IV Flagyl 500 TDS

3. Fluid resuscitation

3. IV Tramal 50mg QID

4. Analgesic

4. IV drip (NaCl)

5. Drainage of obstructed bile ducts

5. Urine output observation

08/04/15

DISCUSSIONS

Ascending cholangitis- inflammation on the biliary tract due to ascending bacterial infection,
associated with obstruction of the bile ducts( partial or complete occlusion of the duct).

Etiology -obstruction by gallstones* which in this patient case, it is the most likely as she
had previous history of diagnosed acute cholecystitis secondary to cholelithiasis. Other
causes of ascending cholangitis are biliary tract interventions and stents, stricture, tumours or
choledochal cyst.

As the patient was previously diagnosed to have symptomatic cholecystitis and it is


possible for the patient to have recurrent episode of acute cholecystitis.

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So, eventhough the provisional diagnosis is ascending cholangitis, there might be chance
of superimposed cholecystitis that was not clinically diagnosed due to the absence of
Murphys sign.

The results of her hepatobiliary system USG and liver plain CT scan gave the
impressions of choledocholithiasis, cholelithiasis and cystic duct lithiasis causing biliary
obstruction. There was also evidence of cholecystitis with cholangitis sonographically.

Conservative management - antimicrobials therapy, pain management, fluid


resuscitation and electrolyte imbalance correction. As the patient has been stabilized, the
obstructed bile duct must be drained. After the acute cholecystitis has been treated,
definitive operative management should be done after proper diagnosis is established.

08/04/15

References
1.

Bailey and Love, 26th edition

2.

Doctrina Perpetua: Guides on Clinical Surgery

3.

Medscape.

08/04/15

TQ. Have a nice day

08/04/15