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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
2
CHIEF COMPLAINT
Patient started
have pain at hypochondriac
HISTORY
OF toPRESENTING
ILLNESS
worsen.
Pain is non-radiating.
forward.
4
No loss of weight.
5
Menstrual History
No complaint of dysmenorrhea.
SYSTEMIC REVIEW
Cardiovascular system
Respiratory system
Genitourinary system
Neurological
system
7
No drug allergies.
SOCIAL HISTORY
FAMILY HISTORY
10
PHYSICAL EXAMINATION
General Examination
Vital Signs
Pulse rate
Breathing rate
12
: 84 beats/min
: 20 breaths/min
Hand Examination
No flapping tremor.
No clubbing.
No peripheral cyanosis.
No koilinychia.
No tobacco stain.
No palmar erythema.
13
No indentation.
No pitting oedema.
14
ABDOMINAL EXAMINATION
Inspection
No surgical scars.
15
Palpation
No palpable mass.
No splenomegaly.
16
Percussion
Auscultation
17
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.
18
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
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
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
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
HOSPITAL MANAGEMENT
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
INVESTIGATION
1.
2.
3.
4.
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