Patients Details

Name : Tohirah Binti Abd Razak

Date of Birth : 4th April 1945

Age : 71 years old

Gender : Female

Race : Malay

Religion : Islam

Marital Status : Widow

Occupation : Housewife

Address : Olak Lempit, Banting

R.N. : 1738681 (HTAR)

Ward : 3B

Date of Admission : 5th June 2017

Date of Clerking : 12th June 2017

Informant : Madam. Khairiza (Patients daughter)

Chief Complaints

Fever for 1 week

Right upper abdominal pain for 2 days
History of Presenting Illness

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,

abdominal distension, dark stool, or constipation.

 On the day of admission, she vomited once, consisting of food particles without

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

easily bruising, itchiness, abdominal trauma, abdominal surgery, consuming traditional

medicine, alcohol consumption, blood transfusion, and usage of illegal intravenous drug,

tattoo, and no family history of similar condition, haematological disease, malignancy, or

hepatitis B infection.
Systemic Review

General Health She was lethargic

No increase in thirst

Gastrointestinal System No dysphagia

No nausea
No blood in stool
No change in bowel habit (constipation, diarrhoea,
tenesmus)
No rectal bleeding
No heart burn

Genitourinary System No changes in frequency

No changes in urine output
No dysuria
No haematuria
No dark coloured urine
No incontinence, no hesitancy
No urethral discharge
No nocturia

Cardiovascular System No chest pain

No palpitation
No leg swelling
No pitting edema
No cyanosis
No orthopnea
No paroxysmal nocturnal dyspnea
No syncopal attack

Respiratory System No sputum

No stridor

Musculoskeletal System No bone pain

 No joint pain
No swelling of joints
No bony tenderness
No muscle weakness

Central Nervous System Confusion

No headaches
No giddiness
No slurred speech
No muscle weakness
No seizure
No faints and blackouts
No hearing loss
No visual disturbance
No memory and concentration changes

Skin No rashes
No itchiness
No discoloration of skin

Endocrine System No rashes

No itchiness
No discoloration of skin
Past Medical History

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

hospitalization due to diabetes mellitus and hypertension.

Past Surgical History

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

T. Metformin (Unsure of dosage)

Allergic History

No known allergy towards drugs or foods.

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

not a dengue endemic area.

Physical Examination

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

side and filled with tea coloured urine.

Vital Signs

Blood pressure : 150/80 mmHg

Pulse rate : 110 beats per minute (tachycardic, regular rhythm, good volume, no

special character)

Respiratory rate : 24 breaths per minute (normal)

Temperature : 37.0C (afebrile)

SpO2 : 96% in normal air (normal)

Pain score : 3/10

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

visible scar, bruises or scratch marks.

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

No palpable lymph node or neck swelling.

Lower Limbs

Peripheries are warm to touch. No peripheral cyanosis, pitting oedema, varicose veins,

scratch marks, or tattoo.

Back

No sacral oedema, surgical scars or any marks. No kyphoscoliosis.

Abdominal Examination

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

guarding, rigidity, or change in skin temperature.

b) Deep

Tenderness over right hypochondrium, otherwise no tenderness on other regions, and no

palpable mass. The liver edge was palpable and hard. Spleen was not palpable. Kidneys

were not palpable. Negative Murphys sign and Rovsings sign.

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

No chest deformities, scars, dilated superficial vein, or visible pulsation.

Palpation

Apex beat felt at the 5th intercostal space on the midclavicular line. No palpable thrill or

parasternal heave felt.

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

scar, dilated vein, or visible pulsation seen.

Palpation

Trachea was centrally located. Normal chest expansion, bilaterally symmetrical.

Percussion

Both lungs are resonant on percussion.

Auscultation

Normal vesicular breath sound heard bilaterally. Minimal crepitation head bilaterally at lower

zone of the lungs.

Summary

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

worsened and colicky in nature.

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

Obstructive Jaundice secondary to choledocholithiasis.

Supporting Points :

Intermittent fever with rigors

Slightly jaundice

Constant right upper abdominal pain radiating to the back on the same side

History of renal calculi

Old age

Slightly distended abdomen

Tenderness on epigastric and right hypochondriac region

Differential Diagnosis

Differential Diagnosis Points Supporting Points Against

Carcinoma of the Weight loss No pale stool

head of pancreas Jaundice No itching

Dark urine No enlarged lymph nodes on

Abdominal pain the neck

Back pain

Ascending Cholangitis Right upper quadrant pain No change in mental status

Fever associated with rigors Hypertension

Dark urine No peritonitis

Jaundice

History of renal stone

Tachycardia

Acute Pancreatitis Upper abdominal pain Not aggravated by food

radiating to the back intake

Fever No relieved by leaning

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

Acute Appendicitis Right upper abdominal pain No constipation or diarrhea

Fever No abscess

Tachycardia No mass in right inguinal

fossa

Negative Murphys sign

Negative Rovsings sign

Investigations I (Done by the Hospital)

Full Blood Count (11th June 2017)

RESULT NORMAL RANGE

HAEMOGLOBIN 11.6 13.0 - 18.0 g/Dl

TWBC 16.97 4.0 - 11.0 10/L

PLATELET 345 150 - 400 10/L

PACKED CELL VOLUME 32.7 40 52 %

Impression : Reduced Haemoglobin and Packed Cell Volume.

Increased Total White Blood Count.

Liver Function Test

ITEMS TESTED RESULT NORMAL RANGE

Total protein 61 66 - 83g/L

Albumin 28 35 - 52g/L
Globulin 33 25 - 39g/L
Alkaline Phosphatase 444 30 - 120 IU/L
Alanine Aminotransferase 51 0 - 35 IU/L
Total bilirubin 147.3 5 - 21 Umol/l

Impression : Increased Total Protein, ALP, ALT, and Total Bilirubin.

Renal Function Test

RESULT NORMAL RANGE

Urea 6.1 3.0 - 6.5 mmol/L
Creatinine 95 60 - 125 mol/L
Sodium 132 135 - 145 mmol/L
Potassium 3.6 3.5 - 5.0 mmol/L
Chloride 96 97 - 107 mmol/L

Impression : No remarkable finding.

Arterial Blood Gas

RESULT NORMAL VALUE

pH 7.47 7.35 7.45

PaO2 64.6 83 108 mmHg

PaCO2 31 35-45 mmHg

HCO2 25.9 22 28 mEq/L

Base Excess 2.0 - 2 - +3 mmol/L

Impression : Compensated metabolic acidosis

Others

RESULT NORMAL VALUE

Serum Amylase 211

C-Reactive Protein 105.83

 Chest X-Ray

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

echogenicity and smooth margins. No focal liver lesion seen.

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.

The portal vein (0.9 cm) is patent and normal in calibre.

Spleen is normal measuring 10cm. No focal lesion seen.

Visualized pancreas appears normal.

No free fluid or ascites.

Impression : Cholelithiasis with common bile duct distal obstruction.

Endoscopic Retrograde Cholangiopancreatography (8th June 2017)

Findings :

a) Duodenum : Diverticulum AT O2

b) Ampulla : Normal looking, no bile flow

c) CBD : Unable to cannulate, guidewire coils back after some distance

d) Cystic Duct Gallbladder : Suspect of impacted stone at distal Common Bile Duct

e) Pancreatic Duct : Cannulated multiple times

Post ERCP Diagnosis : Possible choledicholithiasis

Electrocardiography

Sinus rhythm, no ischemic changes

Per Rectal Examination

Findings :

No palpable mass

Empty rectum
Investigation II (Proposed)

Biochemistry

1. Gamma glutamyl Transpeptidase: To determine the cause of elevated ALP

Any biliary outflow obstruction

2. Random Blood Sugar: Evaluate condition of her diabetes mellitus

Assess pancreas endocrine function

3. Tumour Marker: CA 19-9 for gall bladder carcinoma

Carcinoembryogenic Antigen (CEA) for

carcinoma of large intestine

Alpha-fetoprotein (AFP) for hepatocellular

carcinoma and liver metastases

4. Hepatitis B or Hepatitis C Serology: Assess hepatocellular carcinoma

Imaging

1. Computed Tomography of For suspected carcinoma

abdomen and thorax: To visualise distal CBD, intrahepatic

lesion

2. Magnetic Resonance Diagnostic for cholangiocarcinoma, totally

Cholangippancreatography (MRCP): transected CBD, and bile duct injury

Management

1. Supportive Measures :

a. Rehydration

b. Monitor vital signs

2. Definitive Treatment :: Endoscopic Retrograde Cholangiopancreatography

3. Others :

Intravenous (IV) drip Normal Saline 24 hourly

Allow orally

IV Cefobid 2g stat (Antibacterial)

IV Flagyl 500 mg stat tds (Metronidazole, Antibacterial)

Strict urine input and output chart

Final Diagnosis

Ascending cholangitis secondary to choledocholithiasis

Discussion
References

1. Williams, N. S., & Bulstrode, C. J. (2013). Bailey and Love's Short Practice of

Surgery (26th ed.). Taylor & Francis Ltd.

2. Browse, N. L., & Black, J. (2005). Browse's Introduction to the Symptoms & Signs of

Surgical Disease (4th ed.). Taylor & Francis Ltd.

3. McLatchie, G., & Borley, N. (2013). Oxford Handbook of Clinical Surgery (4th ed.).

Oxford University Press.

4. Andersen, F. (2010). Schwartz's Principles of Surgery (10th ed.). McGraw Hill

Education.

5. Phillips EH. Laparoscopic transcystic duct common bile duct exploration--outcome

and costs. Surg Endosc.

6. Heuman, D., MD. (2017, March 31). Gallstones (Cholelithiasis). Retrieved July 09,

2017, from http://emedicine.medscape.com/article/175667-overview

Discussion