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  • Ercp Tn. Hans Lionardy

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    Samsul Bahri
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    This document provides information about a 69-year-old male patient who presented with abdominal pain following surgery. Key details include: - The patient had a history of diabetes, hypertension, and recent gallbladder surgery. He reported abdominal pain for 2 weeks. - Examination and labs showed normal vital signs with elevated liver enzymes. Imaging found renal cysts, enlarged prostate, and pneumonia. - The clinical assessment was suspected bile leakage post-cholecystectomy. The planned procedure was ERCP to further evaluate.

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    This document provides information about a 69-year-old male patient who presented with abdominal pain following surgery. Key details include: - The patient had a history of diabetes, hypertension, and recent gallbladder surgery. He reported abdominal pain for 2 weeks. - Examination and labs showed normal vital signs with elevated liver enzymes. Imaging found renal cysts, enlarged prostate, and pneumonia. - The clinical assessment was suspected bile leakage post-cholecystectomy. The planned procedure was ERCP to further evaluate.

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    21 views12 pages

    Ercp Tn. Hans Lionardy

    Uploaded by

    Samsul Bahri
    This document provides information about a 69-year-old male patient who presented with abdominal pain following surgery. Key details include: - The patient had a history of diabetes, hypertension, and recent gallbladder surgery. He reported abdominal pain for 2 weeks. - Examination and labs showed normal vital signs with elevated liver enzymes. Imaging found renal cysts, enlarged prostate, and pneumonia. - The clinical assessment was suspected bile leakage post-cholecystectomy. The planned procedure was ERCP to further evaluate.

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    © All Rights Reserved
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    of 12

    Endoscopic Retrograde

    Cholangiopancreatography (ERCP)
    Monday, 4 October 2021

    DPJP & Operator : Dr. dr. Nu’man AS Daud, Sp.PD, K-


    GEH
    Patient Identity
    • Name : Mr. Hans
    • Birth of date : 3 December 1951 (69 years old)
    • MR : 948322
    • Address : Makassar
    • Job : Swasta
    • Marital status: Married
    • Hospital : Wahidin Sudirohusodo, 4nd Floor PJT Room
    408
    Anamnesis
    • Chief complaint : Abdominal pain post operation
    • Abdominal pain (+) in the epigastric regio since 2 weeks ago, pain is like stabbing
    and does not spread. History operation in Stella Maris Hospital ± 1 week ago
    • Fever (-), Nausea (-), Vomiting (-), Jaundice (-)
    • Defecation normally, Uriantion normally
    • History of Diabetes mellitus since 20 years ago, regular treatment with Gliclazid
    60 mg, Dapagliflozin 10 mg, Vidagliptin 50 mg/Metformin 850 mg, Pioglitazone
    30 mg
    • History of hypertension since 10 years ago, not routine treatment with bisoprolol
    Physical examination
    • Weight 72 kg, Height 160 cm
    • Composmentis/Moderate ill
    • TD 140/80, HR 88 x/mnt, RR 20 x/mnt, S: 36,6⁰C, SaO2 99% (without modality)

    • Eyes : conjunctiva no pale, sclera no icteric


    • Neck : JVP R+0 cmH2O, lymphadenopathy (-)
    • Heart : Heart sounds I-II regular, murmurs and gallops not exist
    • Lungs : Vesicular, rhonchi and wheezing not exist
    • Abdomen : Scar of surgery (+), Drain (+), Normal bowel sounds, tenderness (-),
    liver and spleen not papable, Courvoisier sign (-), Ascites (-), No mass palpable
    • Extremities : warm acral, CRT <2 seconds, no edema
    Laboratory Finding
    29/9/21 2/10/21 GDS 161->292
    WBC 10.600 - Albumin 3,5
    HGB 9,9 -
    Protein total 5,9
    PLT 339.000 -
    Globulin 2,4
    PT - 10,4
    INR - 1,00
    APTT - 23,8 Anti-HCV Non reaktif
    Ureum 18 - HBsAg Non reaktif
    Creatinin 0,9 - Swab PCR Negatif
    SGOT 156 - (29/09/21)

    SGPT 152 -
    Natrium 133 -
    Kalium 3,1 -
    Bil.total 2,52 -
    Bil.direk 1,73 -
    MSCT Abdomen without contrast
    (29/9/2021)
    MSCT Abdomen without contrast
    (29/9/2021)
    MSCT Abdomen without contrast
    (30/9/2021)
    Impression:
    • Renal cyst dextra
    • Hypertrophy prostate
    MSCT Thorax (29/9/2021)
    • Pneumonia sinistra
    • Fibrotic lung bilateral
    • Atherosclerosis aortae and
    branch of coronaria artery
    Assessment
    • Post cholesistektomi suspek leakage biliar
    Planning
    • Pro ERCP (4/10/2021)

    Preparation before ERCP :


    • Fasting from Sunday 12 PM until the procedure is finished
    • Meloxicam 15 mg/supp anal (before transfered to the Gastro Centre)
    Thank You

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