PLAN:

1) Allow discharge
2) Discharge with mist
KCL TDS.
3) C. Tramal 50 mg TD
4) C.pantoprazole 40 m
OD.
5) TCA SOPD 2/52 with
repeated LFT an FB
6) Memo to KK for STO
D10.
7) TCA stat if increase
pain, fever &
vomiting.

DX :PANCREATITIS( IMRIE :2)

USG HBS(29/10/15:1)Hepatosplenomegally.

NAZATUL
SHIMA BINTI
KAMARUDIN
5

2)Choledocholitiasis with
right intrahepatic duct calculi
resulting in biliary
obstruction.

840108085
002

3)Normal appearance of
pancreas.

1600881

ERCP(2/11/2015):
Finding :Post duodenitis
Ampulla;-stone at
ampulla bulging
almost extruded.
CBD :-not dilated,
unlike what is seen in
CT only bile debris
throughout no often
stone seen.
Post op dx:
Choledochholithiasis.

HASNAH
BINTI
ABDULLAH
470714105
610
1600814
Advanced
pancreas Ca
with liver
metastasis
Dx in
24/7/15

68.
2

U/L: Adv pancrease ca with

liver metastasis
Pt come to clinic on 28/10/15
for appt with MR ANNAL,
however he is not around
Case seen by DR Law and
admitted for abdominal pain
Diagnosed for advanced ca
on 24/7/15
HPE: rectum: tubular
adenoma, mild dysplastic
Enhanced CT TAP (2/7/15)
Pancreatic Ca of head
and uncinate process
with
- duodenal
imfiltration, biliary
tract obstruction, and
adherence to
surrounding major
vessels

Diagnosed for
advanced ca on
24/7/15
HPE: rectum: tubular
adenoma, mild
dysplastic
Enhanced CT TAP
(2/7/15)
1. Pancreatic Ca
of head and
uncinate
process with
- duodenal
imfiltration,
biliary tract
obstruction,
and
adherence to
surrounding
major vessels
- liver
metastasis
with left
supraclavicula
r and bilateral

Post op D10: CBD

Exploration & srone remov
Op findings: Single mixed
CBD stone:3.5cm
Impacted @lower CBD:
removed

Adhesion noted between

stomach to ant. abdomina
wall
Issues: SSI
Competed IV Cefobid &
Flagyl x10/7
IX:
FBC; 9.5/22.53/255/27.5%
RP:5.2/125/2.7/82/67

- liver metastasis with

left supraclavicular
and bilateral axillary
lymphadenopathy
2. Bulky anterior uterine
cevix
3. bilateral chronic loculated
empyema with subplueral
fibrosis and granuloma
suggestive of old
infection/PTB
4. Left proximal femoral lytic
bony lesion with sclerotic rim
most likely bening nature
OGDS( 10/7/15)
No significant evidence of
gastric outlet obstruction
P/W:
1)
2)
3)
4)

Abdominal pain x2/7

Lethargic x2/52
LOA
Unable to sleep

axillary
lymphadenop
athy
2. Bulky anterior
uterine cevix
3. bilateral chronic
loculated empyema
with subplueral
fibrosis and
granuloma
suggestive of old
infection/PTB
4. Left proximal
femoral lytic bony
lesion with sclerotic
rim most likely
bening nature
OGDS( 10/7/15)
No significant
evidence of gastric
outlet obstruction

USG (19/9/15)
CHOLEDOCHOLITHIA
SIS CAUSING BILIARY
OBSTRUCTION
-SEGMENT 2 LIVER
LESION MAY
REPRESENT FOCAL
CALCIFICATION
DDX: HAEMANGIOM
ERCP
- Duodenum narrow
pylorus / deformed
anatomy (?previous
surgery)
- ampulla bile duct
flow +
-CBD gross dilated
large stone > 2 cm
MULTIPHASE LIVER
28/9
CHOLEDOCHOLITHIA
SIS causing biliary
obstruction
-segment 2 liver
hemangioma
-bilateral renal calculi
with no obstructive
uropathy

LFT:62/24/38/24.6/8/560
CRP: 79.07
Bile cts: Mixed growth
Noted pus discharge from
op-site.

Currently- No Abdominal
pain.
o/e: alert, pink, jaundice.
Bp:101/58
PR: 90 (good volume,
regular)
Abdominal exam exam:
hepatomegally palpable ,
finger.
Plan:
1. Monitor Vital Sign.

2.to discuss with MR. Anna

regarding ERCP

Bilateral simple renal

cortical cyst (bosniak
1)
P/W:
FEVER X 2/7
-assco with chills and
rigors
VOMITING X 2/7
-post-prandial
Poor oral intake
Low- unable to
quatify
No abd pain, no
obstructive
symptoms
BP on arrival 72/48
GCS FULL
VBG ph 7.28, HCO3:
13.6, LAC 9.8
TWC: 30.04
PT/APTT: 23.2/180
FLUID RESUSCITATED
STARTED ON IVI NA
DOUBLE STRENGTH
WEANED DOWN
WITHIN <24HRS. IVD
Off in view of
overloading the
patient. On T Digoxin
and on close Medical
Team monitoring
CXR: PERIHILAR
HAZINESS
COMPLETED 2 PINT
PC TX AND 2 UNITS
FFP
NO AUDIBLE
WHEEZING - REVIEW;
ABG NORMAL
-IMPROVED WITH
NED COMBIVENT AND
IV HYDROCORT
ERCP for

20

Dx with:

MUNIAMM
AL A//P
MARIMUT
HU
31082071
5276
1600841

Post ERCP dx:

Periampullary
Tumor.

1)UGIB

Post ERCP
Instruction:

2)Obstructive jaundice 2 distal CBD

84

3)Li # compression

Check fitness
for GA

USG Abdominal(28/10/2015)

Kiv retry ERCP

1-biliary obstruction.
2 gallblader sludge
Bilateral small kidney.

Trace biopsy
Rx:-PPI 40 g BD

Ct Abdomen (28/10/2015)

O2 NP.

1)biliary obstruction likely

secondary to run calcified CBD
stone or sludge.
2)Splenic varices
3) L1 compresion fracture.
4) lumbar spondyliosis.
OGDS-(29/10/2015) Hiatus hernia
Cholelithiasis.

34

KATIAH
BINTI
JEMAKIN
1600693
38060101
5230
Imp: gall
stone
pancreatiti
s

77.
3

NKMI
Pt referred from H. Tg. Karang for
acute pancreatitis
P/W : 28.10.2015
1. Abdominal pain x 1/52
2. LOA x 2/12
3. Abdominal distention
4. BO & PU normal
USG ABDOMEN (28.10.2015)
- cholelithiasis
- bilateral early renal parenchymal
disease. No sonographic evidence
of obstructive uropathy.
- GB is well distended with few
calculus seen wthin, largest in the
fundus, measuring 0.9 cm. GB wall
is not thickened. CBD and

O/E:
Afebrile, no SOB,
tolerating orally,
ambulating,PU/ BO
+, no vomiting,mild
abdominal pain.
o/e
Alert,
conscious,pink, not
tachypnic.
BP:140/80
PR:78
T:37c
SPo2:100 %
Lungs: bibasal
crepts B/L.
CVS:DRNM
PA : bowel sounds

PLAN
1. Refer
medical
kiv
tochang
e
antibioti
c.
2. Keep
NPO2.

normal.
-not distended.
Heam :
Hb- 10.9
Wbc-31.08
Platelet-464
Pcv-29.5

intrahepatic ducts are not dilated

Renal function
Urea 4.6
Na-138
K -3.0
cl-91
sr.creat-62
blood gases
Ph-7.46
O2-92.7
Co247.6
Hco331.7

29

.
malay/female
NKMI/NKDA
NORZIZA
BINTI
RIDWAN
31
83121606
5194

p/w Abd. Pain x 2/7

-epigastric pain at right
hypochondrium
-colicky in nature.
-not radiating.
Not associated with food intake
-had similar episode about once
a month.

1601587
2-vomiting x 1/7
-2 episodes.
-food particles.
Yellowish discoloration.
No blood.
No fever
No diarrhea
L.O.A x2/7, no loss of weight.
No recent travel

Currently.
-No fever
-No nausea
-no vomiting
-minimal tea color
urine
- no abdominal
pain.
O/E-mild jaundice,
hydration is fair ,
Bp: 107/63
Pulse : 82
T :37
LFT improving.
Liver :- soft Nontender.
Impression
Hepatitis

Plan :1) Comple

te
antibiot
ic for
1/52
2) TCA
1/52
SOPD
with
repeate
r LFT
3) Allow
dischar
ge.

SUHANA
BINTI
MOHD
ARIF
78032108
6504
1601023

37

U/L GASTRITIS- NOT FOLLOW UP

SINCE 2004
PATIENT WAS TRANSFERRED IN
FROM MEDICAL.
P/W .Abdominal pain x 3/52
-on & off
-right hypochondrium.
Burning & colicky.
-radiate to the back.

USG HBS done

(30/10/15)
1.Echogenic
lesion within.
Dilated CBD.likely
soft stone causing
biliary dilatation.
Suggest ERCP
correlation.
2.Cholelitiasis.

2.Vomiting x 3/52
-food particles.
-clear fluid.
-no blood.
-3-4 episodes.

Plan:-NPO2
-Iv
Pantoprazole
40 mg BD
-Monitor
BP/PR hourly,
-Off drips,
-Allow orally.
-For internal
cholecystecto
my.

GB well
distended.
-few stone.
3.Fatty liver

3.Diarrhea x 3/52
-a/w abd. Pain.
-3-4 /d
-brown stool, watery.
4.Tea color urine x 3/52
5.itchy rashes on RHC
h/o fever 1 episode in ED.
Currently- no. abdominal pain
-no vomiting/no nausea.
-tolerating orally.
-No active complain.
A- Alert, conscious, mild
jaundice pain,pink.
BP: 120/70
HR: 77
T :37.
PR: 18
p/s :0
15

RAMLAH

ERCP
done(4/11/15).
Endoscopic
finding:- Ampulla
protuberant;
papilotomy done,
bile clear.
CBD- CBD dilated
and both R & L
main hepatic duct
dilated.
Post op- dx:
Choledocholitiasis
, duct cleared
stone < 1 cm
noted at the
confluence.
Further plan : for
interval
cholecystectomy
later.
Currently

Plan :

BT
BURHAN
39

u/L-gastritis-no scope done.

H/o admission in 2010-ICU-? SOB
d/t epigastric pain claims usg
done under GP- gallstone(2010)
-No ERCP done.
p/w
1-Epigastric pain x 1/52.
-pricking
-radiating to the back.
-increase with meal.
2. Vomiting x 2/7 - > 10
episode/ day
-food paticles
On & off fever.
No diarrhea.
Pu- Tea color urine.
No SOB/ no Chest pain.
No UTI/ No URTI symptom
No yellowish discoloration.
CXR : No air under diaphgram.
P/R : brownish.
ERCP done (4/11/2015)
Endoscopic finding :
1)bulging ampula. CBD was
dilated ,single large > 1.5 cm
stone.
Pus +++

-afebrile
-no abdominal
pain.
-comfortable.
-no nausea, no
vomiting.

1)continue Rx
for
cholangitis.
2) for internal
cholecystasis
later.

o/ebp:140/75
p : 70
T:37
Blood
Wbc-10.93
Hb- 9.2
Platelet-240
Pcv-302
Renal profile:
Urea-4
Potassium 3.0
Chloride-97
s. creatinine-44
LFT:
Total protein-54
Alb-27
Globin-27
t.bilirubin-72.3
ALT-107
ALP-210

Post ERCP diagnosis.

Cholangitis 2 to
choledocholithiasis , duct
cleared.
25

NORAPID
AH BT
YATIM
78072010
5872
1601290

42

. E/A LAPARASCOPIC
CHOLEYCYSTO,Y
DX-CHOLEDOCHOLITIASIS
h/o USG that showed
choledocholeythiasis followed by
ERCP stone removed.
Post op D2: laparoscopy
choleycystwctomy.
Dx: cholilitiasis.
Op-finding
1) congested liver

Currently
1) patient is
stable.
2) No other active
complains.
3)no nausea/no
vomiting
o/e: Alert,
conscious,
hydration is fair.

Plan:
1)Allow
discharge.
2) continue
analgesics

36

SITI
ZAHARAH
BINTI
HANAPI

30

withnutmeg appearance.
2) Inflamed gallbladder with
thickened wall.
Multiple gallstone in bladder
u/l Gestational DM with no
medication
consuming jamu after delivery
for months
p/w
Abdominal pain 6/7
at epigastric region pain score
5/10
radiating to the back
pricking in nature
Vomit x 3/7
Water and food particle
Episode 4-5 times
Tea coloured urine 1/52
Yellow discoloration of both eyes
1x52

Vital signs are

stable.
Liver, soft- nontender
Current;y
Still having
epigastric pain
which radiates to
the right side
Nausea but not
vomiting
Headache
NBO
No Fever

Vital sign
monitoring,
ERCP

A/ Alert,
conscious,
jaundice
BP 130/90
PR 84
T: 37
US Abdomen
(5/11/15)
1. Cholelithiasis
and
choledocholithiasi
s with biliary
obstruction.
LF
Ttl protein: 69
Albumin: 40
Globulin: 29
Bilirubin 65.5
ALT: 434
ALP: 186

27

NG POH
LENG
1601328
65082410

Hb: 12.4
TWBC: 7.42
Plt: 346
Viral Screening:
NR
LDH: 353

50
U/L : DM 20 YEARS
( S/C MIXTARD 28 U BD)
(T. METFORMIN 500MG BD)

C/
No abdominal

TCA SOPD
2/52 TO GET
DATES FOR
LAP CHOLE

6700
30/10/201
5

HPT X 20 YEARS
( T. PERINDOPRIL 4 MG OD)
(T. ASPIRIN 75MG OD)
(T. BISOPROLOL 1.25 MG OD)
(T. SIMVASTATIN 40MG ON)
ANGIOGRAM IN 2013 AT PPUM
- NO BLOCKAGE
P/W
ABDOMINAL PAIN X 1/7
At Epigastric region
Cramping pain in nature p:s 6/10
Radiates to the back

pain
No Vomiting/ No
Nausea
Tolerating Orally
No SOB/ No Chest
pain
Abx Given
(iv Cefobid & Iv
Flagyl)Day 3

Vomiting x 1/7
Postpradial , 5- 6 episodes,
Food particle and water
No blood/ no bile stained

O/E
Alert, Concious,
CRT < 2
BP: 110/80
PR: 84 good
volume
T: 37
RR: 18
PS: 0

No Diarrhea/ No Fever / No UTI/

No URTI/

Lungs: Clear A/E

equal

* Patient has been taking cherry

leaf and boil it and drinking it for
the past 20 years, once a week.

Abd: tenderness
over epigastric
region

USG ABDOMEN on the 02.11.15

Impression
1. Dilated CBD with echogenic
focus within possibly stone or
sludge.
2. Fatty liver with focal fatty
sparing.
3. No evidence of obstructive
uropathy.

I:
Choledocolithiasis
5th November
2015
Hb: 12.9
Twc: 7.65
Plt: 345
Hct: 38
Coag
PT: 13.6
Aptt: 45.1
Inr: 1.08
LFT
T.prot : 67
Albumin: 38
ALP: 201
Bili: 14.2
Dir/ind bil:

IV
PANTOPRAZO
LE 40 MG BD

10.8/3.4
Alt: 36
Amylase: 36
Viral Screening:
NR, Hep C, Hep B.

15

65
Seah
Thoy Kaw

Iv zinacef
750mg tds
Iv flagyl
500mg tds
u/l DM past 10 years
T. Gliclazide 40 mg OD
Hpt past 10 years
T. Telmizartan 80 mg OD
ALLERGY OF CEFOBID
C/
RIF pain ps 3/10
Radiating to the back
Pricking in nature
For the past 1/52
Low grade fever 1/7
No vomiting/ no nausea
No Sob/ No Chest pain

c. omeprazole
40mg od
o/e
Alert, Concious,
hydration fair,
pink,
BP: 120/70
PR: 88
T: 37.8
DXT: 4.8
Hb: 8.6
WBC: 6.24
Plt: 330
Protein: 68
Albumin: 34
Globulin: 34
Bilirubin: 1.0
Alt: 10
Alp: 141
Creat: 61

t. simvastatin
40mg on
t.
multivitamin
iv tramal 50
mg qid
t. ferrous
fumarate 1/1
od

31

71
KHOR
BEE HON
Start iv NS 1
pint
T. Amilodipine
10 mg
DXT qid
Trace S card

U/L
DM for past
On T. metformin 1g BD
s/c insulin 8u ON
HPT
T. felodipine 10 mg od
T. bisoprolol 25 mg od
T. Telisartan 50 mg od
h/o hysterectomy 22 years ago
p/w
Abdominal pain 1/7
Right upper abdomen and
epigastric pain with pain score
8/10
Vomiting 1/7
Food and water content
3 episodes
No blood and no bile stained
No diarrhea/ no constipation
No hematuria/ no dysuria
No fever
Previously went to ED with
similar complaint, US HBS done
(9/9/15) GB stone and was given
TCA SOPD,
But patient didnt attend TCA.

Currently/
No abdominal
pain
No nausea/ no
vomiting
Tolerating orally
well
No sob/ no chest
pain
No fever
o/e
Alert, conscious,
hydration good,
BP: 160/60
PR: 80
T: 37
Ps: 0/10
Hb : 12.3
WBC: 16.37
Plt: 245
Pt/PTT: 15.1/43.4
Inr: 1.25
LFT:
Total prot: 66
Alb:38
Globulin: 28
T.Bili: 81.5
ALT: 424

ALP: 200
AST: 145
LDH: 395
CRP: 111.93

I: biliary colic