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MAGESWARY NADARAJAH
012012100053
PATIENTS IDENTIFICATION
Gende r: Female
Religion : Islam
Race : Muslim
Occupation : Housewife
Bed number : 12
Ward number : 3A
Informant : Patient
CHIEF COMPLAINT
Abdominal pain for 3 days
08/04/15
08/04/15
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
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
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.
Pancreatic Carcinoma
Supporting points-Tea coloured urine
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.
RESULTS
FULL BLOOD COUNT
Value
Unit
11.6
g/dL
11.7
10^9/L
Hematocrit
34.7
Platelet
324
10^9/L
Haemoglobin
08/04/15
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
08/04/15
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
08/04/15
08/04/15
MANAGEMENT
SELF REVIEW
HOSPITAL
1. IV Cefobid 2g BD
2. Nil by mouth
3. Fluid resuscitation
4. Analgesic
4. IV drip (NaCl)
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.
08/04/15
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.
08/04/15
References
1.
2.
3.
Medscape.
08/04/15
08/04/15