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1.

PATIENTS PARTICULAR
Name

: x

Age

: 37 years old

Gender

: Female

Race

: Foochow

Marital Status

: Married

Occupation

: House wife

Address

: Sibu

Date of Admission

: 5th November 2016 / 1630

Date of Clerking

: 6th November 2016 / 1200

2. HISTORY
Chief Complaint
Madam King Seing presented with abdominal pain associated with tea color urine and pale color
stool 4 days prior to admission.
History of Present Illness
The history of presenting illness started 4 days prior to admission. Her abdominal pain
started, it was severe with the pain scale 10/10. It was sudden onset , intermittent pain with
increasing intensity. Each episode of pain lasted for 2 minutes to 30 minutes. Initially, the pain
was relieved by a tracamadol but the pain only subside for few hours. Movement will aggravate
the pain whereas bed rest will sometimes reduce the pain. Sometimes the pain will radiate to the
back. 3 days prior to admission she noticed her urine color was abnormal and it was tea color
like, and the color of stool was abnormal too, pale color stool. 2 days prior to admission she had
itchiness on her limbs. Finally, she noticed some changes on her skin, yellowish and her white
part of the eyes were yellow as well. About her jaundice, at first her son noticed her appearance
of her eyes, but the jaundice was intermittent. She also had an episode of nausea and vomiting it
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was non projectile and the vomitus contain billous particle and non bloody. She also complaint
had an episode of fever with chills and rigor.

Initially, 5 months prior to admission she went to a private clinic due to her same
presenting illness of her abdominal pain except her urine output and bowel output was normal
and there was no jaundice too. She was diagnosed as gallstone but not indicated for surgery. She
was only given medication prescribed by her doctor. The medication was unknown. She claimed
the only medicine she knew was tracamadol as a pain reliever. Due to current development of her
abdominal pain with associated symptoms such tea color urine , pale color stool and jaundice
she was terrified and went to A&E department in Hospital Sibu and

required immediate

hospitalization.
She loves to eat fatty food when she was youthful.

Review of System
SYSTEM
Cardiovascular

FINDINGS
There was no precordial pain.

Respiratory

There was no shortness of breath and no cough,no sore throat or


no nasal bleeding.

Gastrointestinal
Genitourinary

No early satiety and hunger pain. No loss of appetite.


There were no hematuria and dysuria. Urine output and frequency
are as usual.

Central Nervous

No headache, no disturbance of vision and no loss of

Musculoskeletal
Haemotological

consciousness,
Easy fatigability and generalized malaise..
No external bleeding was noted.

Past Medical/Surgical History


No significant past medical surgery except she had lower segment caesarean section surgery for
her last child which was 11 months ago.
Obstetrics and Gynecologic History
She is married with 4 children. All her children born spontaneous vaginal delivery except for the
last one with lower segment caesarean section surgery. Her first pregnancy was on year 2011,
recently she delivered her baby on July 2016.
Her last menstruation was on 15th October 2016 . She had her menarche at age 12 and claimed to
have regular menstruation until now. No dysmenorrhea during menstruation were noted. No
dyspareunia.
Family History
No significant findings of her family history.
Social History
She is a non smoker and she does not consume alcohol beverages. She also claimed does not
tried any traditional medicines before. She is a housewife. She lives in Sibu. Her house
approximately 30 minutes distance from Hospital Sibu. She lives in a brick house with a proper
access of power and water supply.

Drug History
No significant drug history recorded.

Summary
Madam Ting King Sieng, a 37 years old mother presented colicky pain at right upper quadrant
which radiate to back and associated with tea color urine, pale color stool and intermittent
jaundice, with one episode of billous vomiting and an episode of fever with chills and rigor. She
is a non smoker and non alcoholic.
_____________________________________________________________________________
3. PHYSICAL EXAMINATION
General Inspection
On inspection, she was conscious, alert and well-oriented. The patient was lying comfortably in
supine position with slight raised (30) of head supported by two pillow. There were no sign of
respiratory distress and no sign of gross deformity. There was a branula inserted on the dorsum
of her right hand. The patient is moderately built.
Vital Signs (13th September 2016)
Blood pressure

: 127/80 mmHg
The blood pressure is normal. (Normal=120/80 mmHg)

Heart Rate (HR)

: 85 beats per min


The heart rate is normal. (Normal HR= 60-100 beats/min)

SPO2

: 100% (room air)


Normal (Normal SPO2= 95%)

Temperature

: 36.8 C
The patient is afebrile. (Normal Body temperature = 37C)

Respiratory rate (RR) : 22 breaths per min


The respiratory rate is normal (Normal RR= 12-20 breaths/min)

General Examination
General Examination
Hand

Findings
The palm was warm, slightly dry and pale.
No signs of clubbing.
No peripheral cyanosis.
No signs of koilonychias or leukonychias.
No wasting of thenar eminence muscle.
No significant sign of tenderness on her left hand but was noted on her
right hand particularly dorsum region due to branula.
No present of old scars around her hands.

Head and Face

No hepatic flap (asterixis) was noted.


No conjunctiva pallor which indicates absent of anaemia.
No yellow discolouration of sclera which means no jaundice.
No central cyanosis.
No angular stromatitis.
No glossitis.
Oral hygiene is excellent.
Mucosa was moist and no dental carries were present.

Neck

No swelling was noted in the neck region.


No tracheal deviation.
All lymph node were not palpable.

Chest

The skin was normal in colour.


No spider naevi.

Lower Limbs

No rashes.
Absent of edema.

Specific Examination (Abdominal)


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Abdominal Examination
Inspection

Findings
The abdomen moves with respiration.
No scars were noted.
No abdominal distension.
The navel is centrally located and not inverted.
No dilatable vein or pulsatile were present.
Striae gravidarum was noted due to previous pregnancy.

Superficial Palpation

Abdomen was soft with no tenderness.


No palpable mass.

Deep Palpation

No palpable mass.
No tenderness upon deep palpation.
Murphys sign negative.

Liver and Spleen Palpation

Liver and spleen were not palpable.

Kidney palpation
Percussion

Kidney is not ballootable.


Resonance was noted all over the abdomen.

Auscultation

Bowel sound present at normal intervals.

Systemic Examination
Systemic Examination
Findings
Cardiovascular
Upon auscultation, normal S1 and S2 sound were heard.
No heart murmurs.
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Respiratory

No abnormal sounds (rhonchi, wheezing, and crepitation) were heard


during inspiration and expiration.

Summary
Upon examination, the abdomen was soft with no tenderness noted upon superficial and deep
palpation. There was presence of striae gravidarum due to her recent pregnancy. No other
significance finding was noted.
_____________________________________________________________________________
4. PROVISIONAL DIAGNOSIS
Cholelithiasis
Positive Findings
Pain at epigastric and right hypochondrium

Negative findings
-

region.
Repeated attacks of pain associated with
vomiting and diarrhea.
Pain was aggravated with oily and fatty meal
intake.
Colicky pain.
Risk factor woman, preferred fatty food.
Negative Murphys sign much indicate biliary
colic instead of cholecystitis.

5. DIFFERENTIAL DIAGNOSIS

Differential Diagnosis

Positive Findings

Negative Findings

O
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Gastric ulcer

Pain at epigastric region.

Spreading of pain from

Nausea and vomiting.

epigastric

Pain after food intake.

hypochondrium region.

Long-standing gastritis may No


lead to gastric ulcer.

to

right

hematemesis

and

malaena were noted.

Diarrhea.
2

Acute Cholecystitis secondary Pain at epigastric and right Murphys sign negative.
to cholelithiasis

hypochondrium region.
Nausea,

vomiting

diarrhea.

Afebrile.
and Pain start 3 years ago with
worsening symptoms does

Pain after intake of fatty and not suggest acute pain.


oily food.
3

Pancreatitis
cholelithiasis

secondary

to Pain at epigastric region.

Cullens sign negative.

Nausea and vomiting.

Mild intake of alcohol.

Diarrhea.

No spreading of pain to
the back.
Pain was not involving left
hypochondrium which is
most common site to be
affected.

6. PROPOSED INVESTIGATIONS

I.

Full Blood Count


To assess total white cell count in identification of infection and inflammation.

II.

Liver Function Test


To exclude any disease related to liver and to assure normal function of liver.

III.

Amylase level
To exclude any pancreatic diseases.

IV.

Renal Function Test


To assess the renal function such as excretion and also to monitor any electrolyte
(sodium, potassium) imbalance to prevent any complications such as cardiac arrest,
edema, heart failure and acute kidney failure.

V.

Ultrasound Abdomen
Used to confirm the diagnosis of cholelithiasis and identifying any findings on
cholecystitis.

VI.

Oesophagogastroduodenoscopy (OGDS)
To exclude peptic ulcer disease.

___________________________________________________________________________

7. ACTUAL INVESTIGATIONS
Full Blood Count : 6th November 2016

I.

Parameters

Results

Reference Range

Unit

White Blood Cell

8.1

4-11

103/uL

Hemoglobin

13.3

11.5-15.5

g/dL

Platelet

247

150-400

103/uL

Intepretation : All blood components are within normal range.


II.

Renal Function Test : 6th November 2016

Parameters

Results

Reference Range

Unit

Sodium

138

137-149

mmol/L

Potassium

3.5

3.8-5.2

mmol/L

Chloride

106

97-107

mmol/L

Urea

2.9

1.7-8.3

mmol/L

Creatinine

76

44-106

umol/L

Intepretation : All kidney constituent test are within normal range except for potassium level
which is slightly low.
III.

Haemostasis Test : 6th November 2016


Parameters

Results
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Prothrombin time (PT)


Activated Partial Thromboplastin time (aPTT)
International Normalised Ratio (INR)

13s (control = 13s)


34s (control = 39s)
1.03

Liver Function Test :6th November 2016

VII.

Parameters

Results

Reference Range

Unit

Total bilirubin

9.7

3-17

umol/L

Direct bilirubin

1.5

0-3

umol/L

AST

49

15-37

IU/L

ALT

50

12-78

IU/L

Total protein

73

64-82

g/L

Albumin

40

35-50

g/L

Globulin

31

23-35

g/L

Alk Phosphatase

128

50-136

IU/L

Intepretation : All were normal except for AST which is elevated.


VIII.

Ultrasound abdomen
Findings : Liver is normal in size. However, echogenicity is diffusely increased but
margin is smooth. No focal lesion seen. Gallbladder moderately distended with multiple
calculi within. No wall thickening and no pericholecystic fluid seen. Common bile duct
and intrahepatic duct are not dilated. Portal hepatic vein are patent. Spleen is normal
measuring 9.0 cm. No focal lesion. Visualized pancreas is normal. No ascites.

IX.

Oesophagogastroduodenoscopy (OGDS)
Findings : Oesophagus normal. No hiatal hernia, stomach normal, D1 and D2 normal.

________________________________________________________________________
8. MANAGEMENT
i.

Pre-operative preparation to ensure patient is fit to undergo operation.


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ii.

Laparoscopic cholecystectomy to remove the gallbladder.

iii.

Surgery planned by doctor in charge is laparoscopic cholecystectomy keep in view open


cholecystectomy.

___________________________________________________________________________
9. DISCUSSION
The gallbladder is a small , pear-shaped, muscular storage sac which located at the inferior
border on the right side of a liver. It is located around the 9 th costal cartilage. The gallbladder is
about 7.5-10 cm long and about a 2.5cm wide. It is made up of 4 layers of tissue. Mucosa is the
innermost layer which consist of epithelium and lamina propria (loose connective tissue). A
muscular layer, perimuscular layer which covers the muscular layer and most outer layer is
serosa which covers the whole gallbladder. The gallbladder has 3 parts fundus, body and neck.
The fundus is the bottom of the gallbladder that protrudes from under the liver and visible
anteriorly. The body is the main dilated portion of the gallbladder that lies between the fundus
and cystic duct. The neck of the gallbladder is the narrower part that points into cystic duct.
Arterial supply to the gallbladder is through cystic artery which arises from right hepatic artery.
Venous drainage is via cystic vein which mainly accounts for the drainage of the neck and cystic
duct. The venous drainage of the body and fundus of gallbladder is directly into the visceral
surface of the liver and through the hepatic sinusoids. Lymph drains into the cystic lymph nodes
which empty into the hepatic or celiac lymph node.
The primary function of gallbladder is to store and concentrates the bile produces by the liver.
Other than that, the gallbladder secretes bile by muscular contraction of its wall in response to
both hormonal and neural factors stimulated by food especially fatty food. Bile consist of bile
salts, electrolytes (sodium and bicarbonate), bile pigments (bilirubin and cholesterol). Bile is
responsible for the elimination of waste products from the body particularly pigment from
destroyed red blood cells and excess cholesterol and assists in the digestion and absorption of
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fats. Bile salts increase the solubility of fats and fat-soluble vitamin (A,D,E,K) to aid in their
absorption from the intestine.
The pathway of bile production from liver to gallbladder can be summarized as; bile flows out of
the liver through left and right hepatic duct which comes together to form common hepatic duct.
Common hepatic duct then joins the duct that connected to the gallbladder which is cystic duct to
form common bile duct. Common bile duct enters the duodenum at the sphincter of oddi where it
joins pancreatic duct.
About half the bile is secreted between meals is diverted through the cystic duct and into the
gallbladder, where bile is stored. In the gallbladder, up to 90% of the water in the bile is absorbed
into bloodstream, making the remaining bile to be concentrated. When food enters the
duodenum, a series of hormonal and neural signals trigger the gallbladder to contract and the
sphincter of oddi to relax and thus open. Bile then flows from the gallbladder into the small
intestine to mix with the food contents and perform its digestive functions.
Gallstones formation occurs because certain substances in bile are present in concentrations that
approach the limits of their solubility. When bile is concentrated in the gallbladder, it can become
supersaturated with these substances, which then precipitate from the solution as microscopic
crystals. The crystals are trapped in gallbladder mucus, producing gallbladder sludge. Over time,
the crystals grow, aggregate, and fuse to form macroscopic stones. The 2 main substances
involved in gallstone formation are cholesterol and calcium billuribinate. Mixed gallstones
sometimes may present but 80% of patient present with cholesterol type of gallstones.
Gallstones formation may cause several complications if not treated. Distended gallbladder is
common when gallstones formation is excessive. Gallstones may obstruct the flow of bile from
the gallbladder, causing pain in biliary colic condition. The pain will aggravated when eating
fatty food due to increase contraction of gallbladder to secretes bile, but due to obstruction, much
force is needed which will then induces pain. Inflammation of gallbladder, cholecystitis is a
common presentation secondary to cholelithiasis. Most of the patient with cholelithiasis will end
up having cholecystitis as their complications. Gallstones may also migrate from the gallbladder
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to common bile duct where they can block the normal flow of bile to the intestine, which results
in jaundice.
Cholelithiasis disease may be symptomatic and asymptomatic or silent gallstones. The most
common presentation of patient with cholelithiasis are biliary colic (56%) and acute cholecystitis
(36%). Epidemiologically, 10-15% of adult population develop gallstones and laparoscopic
cholecystectomy have become most common surgery done annually. Even though patient may
not show symptoms at initial state, eventually it will lead to further complications that require
surgical removal of gallbladder.

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