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Gender : Female
Race : Malay
Religion : Islam
Occupation : Housewife
Ward : 3B
Patient has a history of left renal calculi diagnosed on 2016 at Hospital Kuala Lumpur
and laser treatment (Short Wave Lithotripsy) was done. The last scan during follow up
treatment showed absence of calculi. Besides that, she also has underlying diabetes mellitus
and hypertension.
3 months prior to the day of admission, she noted loss of appetite. She usually has 3
meals a day, but she only drank milk and had 5 to 6 spoons of solid food a day. She also noted
loss of weight as evidenced by looser clothes however she was unsure of amount loss.
The fever was sudden onset and intermittent in nature, however temperature was not
recorded at home but it was warm to touch. It was associated with chills and rigors and
yellowish discoloration of the eyes. She took Paracetamol but only relieved for few hours. The
fever was not associated with night sweats, excessive sweating, sore throat, pain on
micturition, or decreased in urine quantity and frequency. She has no history of recent
travelling to dengue or malaria endemic area, water activity, or any sick contact.
The right upper abdominal pain was sudden onset which started at right upper region
to the mid upper abdomen as well. It was progressively worsened and colicky in nature. It
radiated to the back on the same side, without radiating to right shoulder or any other region.
She was unsure if it associated with food intake or meal time. It was not associated with
position, posture, movement, or bowel movement. There was no specific relieving factor,
particularly by leaning forward, after meal, or defecation, nor specific exacerbating factor. The
pain did not disturbed her sleep and pain score on admission was 7/10.
She was brought to private clinic and was given gastritis medication, but did not resolve.
She was unsure about tea coloured urine or pale stool. She did not have complain of diarrhoea,
mucous, greenish fluid or blood. It was not a projectile vomiting. She also had shortness of
breath with unproductive cough, without wheezing. She was confused and did not remember
what happened during the day of admission until she was stabilised at the ward.
Otherwise, there was no chest pain and bilateral pitting oedema. She has no history of
medicine, alcohol consumption, blood transfusion, and usage of illegal intravenous drug,
hepatitis B infection.
Systemic Review
Skin No rashes
No itchiness
No discoloration of skin
She was diagnosed to have diabetes mellitus and hypertension for over 20 years ago. She is
compliance to her medications, on regular follow up at KK Olak Lempit, and has no history of
She has history of procedure done for left renal calculi and admitted for 2 weeks.
Drug History
T. Amlodipine, 10mg OD
T. Perindopril, 4mg OD
Allergic History
Sexual History
She does not have sexual partner for the past 5 years. She attained menarche at 13 years
old and menopause at 50 years old. She did not have any history of menstrual problem.
Family History
The patient is the eighth child out of 9 siblings, all has diabetes mellitus and hypertension.
She has 5 children and the eldest daughter has history of renal calculi while others are
healthy and alive. Her parents passed away due to old age and unsure if they have any
disease.
Socioeconomic History
Patient denied having diet of low fibre and high red meat and not leading a sedentary life
style. She is not a smoker or alcoholic. She is staying with 2 daughters as her husband has
passed away and financially supported by them. The housing area has good sanitation and
General Inspection
Patient was lying comfortably on the bed in supine position supported by two pillows. She is
a thin built and in respiratory distress as evidenced by having nasal prong connected to
oxygen. She looked lethargic and jaundice. She was alert, conscious and well oriented to
time, place, and person. She had ID tag on her right wrist and IV cannula is attached on the
dorsum of her left hand, connected to IV drip normal saline. There is urine bag on the bed
Vital Signs
Pulse rate : 110 beats per minute (tachycardic, regular rhythm, good volume, no
special character)
Hand Examination
Hands are moist and warm to touch. Capillary refill time is less than 2 seconds. No palmar
erythema, clubbing, peripheral cyanosis and leukonychia. No fine and flapping tremors. No
Eye Examination
Has sign of jaundice on the sclera. No conjunctival pallor, corneal arcus, or xanthelasma.
Mouth Examination
Lips were moist and pink, no angular stomatitis. Has sign of jaundice on oral mucosa. No
central cyanosis, gum bleeding or hypertrophy. She has completely lost all tooth. Tongue
was coated.
Neck Examination
Lower Limbs
Peripheries are warm to touch. No peripheral cyanosis, pitting oedema, varicose veins,
Back
Inspection
The abdomen is slightly distended. The flanks were full. Umbilicus is centrally located,
inverted. The abdomen moves symmetrically with respiration. No scars seen, spider naevi,
dilated veins, or visible peristalsis, mass, and pulsation. Hernial orifices are intact.
Palpation
a) Superficial
The abdomen is soft and tenderness on epigastric and right hypochondriac region. No
b) Deep
palpable mass. The liver edge was palpable and hard. Spleen was not palpable. Kidneys
Percussion
Liver dullness at 5th intercostal space, midclavicular line (liver span was 14 cm). No fluid thrill
or shifting dullness.
Auscultation
Normal bowel sound was heard (3 times per minute). No renal and aortic bruit heard.
Cardiovascular Examination
Inspection
Palpation
Apex beat felt at the 5th intercostal space on the midclavicular line. No palpable thrill or
Auscultation
Normal heart sound S1 and S2 heard on all four areas. There were no added sound and no
murmur.
Respiratory Examination
Inspection
Shape of the chest is normal and moves bilaterally symmetrical on respiration. No surgical
Palpation
Percussion
Auscultation
Normal vesicular breath sound heard bilaterally. Minimal crepitation head bilaterally at lower
Madam Tohirah, a 71 years old woman presented to the hospital with chief complain
of fever for 1 week and right upper abdominal pain for 2 days prior to admission. She has
loss of appetite and weight for the past 3 months. The fever was sudden onset and
intermittent in nature, associated with chills and rigors and yellowish discoloration of the
eyes. The abdominal pain was sudden onset which started at right upper region to the mid
upper abdomen as well, radiated to the back on the same side. It was progressively
On physical examination, she was jaundice and had tea coloured urine. The
abdomen was slightly distended with right hypochondriac tenderness. Murphy sign was
negative.
Provisional Diagnosis
Supporting Points :
Slightly jaundice
Constant right upper abdominal pain radiating to the back on the same side
Old age
Back pain
Jaundice
Tachycardia
Jaundice forward
No chest pain
Not alcoholic
Acute cholecystitis Right upper abdominal pain Pain does not radiate to right
Fever shoulder
No guarding tenderness
No nausea or vomiting
Acute cholelithiasis Right upper abdominal pain Pain is not diffused, able to
Fever locate
Pain does not radiate to right
shoulder
No guarding tenderness
No nausea or vomiting
Fever No abscess
fossa
Others
Figure 1 Figure 2
okt
Kidney Ureter Bladder X-Ray
Figure 3
Ultrasonography Hepatobiliary System (5th June 2017)
Figure 4
Findings :
The liver is normal in size (14.5cm in span), with normal echotexture and
Gall bladder is distended with thickened gall bladder wall measuring 0.4 cm. Multiple
calculi in the gall bladder, largest measuring 1.5 cm. No pericholecystic fluid seen.
Common bile duct (1.0 cm) and intrahepatic ducts are dilated.
Findings :
a) Duodenum : Diverticulum AT O2
d) Cystic Duct Gallbladder : Suspect of impacted stone at distal Common Bile Duct
Electrocardiography
Findings :
No palpable mass
Empty rectum
Investigation II (Proposed)
Biochemistry
Imaging
lesion
1. Supportive Measures :
a. Rehydration
3. Others :
Allow orally
1. Williams, N. S., & Bulstrode, C. J. (2013). Bailey and Love's Short Practice of
2. Browse, N. L., & Black, J. (2005). Browse's Introduction to the Symptoms & Signs of
3. McLatchie, G., & Borley, N. (2013). Oxford Handbook of Clinical Surgery (4th ed.).
Education.
6. Heuman, D., MD. (2017, March 31). Gallstones (Cholelithiasis). Retrieved July 09,