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CASEREPORT A.W.S General HospitalSAMARINDAFriday, March 13th 2015
AdvisorDr. Dompak S. H, Sp. RadResidentDr. Radityo Budi L (DIT)
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Adm. Date : 21/02/2015Name:Ny. HSex:FemaleAge:31 yoMR:
Chief complain:Pain at right Upper abdomenHystory taking:Pain at right upper abdomen suffered since 4 month before admitted to Hospital, the pain felt sharp and radiating to the back of the right shoulder. Initially the pain felt seldomly but on last week the pain felt more often. Fever (+), Nausea (+), Vomiting (-). Urine color changed into tea like color, Feces color is Blackish green.Examination:Physical examination, Laboratory examination, Radiology Exam
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Physical Examination*
Anemic +/+ Icteric +/+Thorax : Within normal limitAbdomen : Distended (-)Tenderness (+) at RUQ, Murphy Sign (+), Hepatomegaly (+),TympanicBowel Sound (N)Flank : Flank pain -/-, Flank mass -/-, CVA tenderness -/-, Bulging bladder (-), Genitalia normal
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LABORATORY RESULT
Complete Blood CountDate : 21/02/2015WBC:10,2 x 103 / LRBC:4,79 x 106 / LHGB:7,9 g/dLHCT:31,7 %PLT:223 x 103 / LBT / CT:200 / 900Blood Sugar:95 mg/dlUreum:23 mg/dlCreatinin:0,9 mg/dl
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LABORATORY RESULT
Complete Urination CountBJ:1.015Ketone:-Nitrit:-Leuko:-Hb/blood:-Color:Thick YellowPurity:CloudypH:6,5Protein:+1Glucose:-Billirubin:+3Urobilinogen:+2
Epithel:+Leuco:1-2Erytro:0-1Silinder:-Crystal:-Bacteria:-Fungi:-
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WORKING DIAGNOSIS :Suspect Obstructive Icterus + Abdominal pain due to suspect GallstonesDD : Cholecystitis Management:TherapyIVFD RL 1500cc/24hInj. Ceftriaxone 1gr/12hInj. Anthrain 1gr/8hInj. Ranitidin 50mg/12hCurcuma tab 3x1
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Follow upDate : 22/02/2015S : Abdominal pain, Menstruation (-)O : VS : TD 90/60 N 82 RR 18 Temp : 36,4Anemic +/+, Icteric +/+Abdomen : No clinical changesLab : Hb 7,9A : Obstructive Icterus + Abdominal pain due to suspect gallstones, DD : Cholecystitis + secondary amenorhea + AnemiaP : Continue existing TherapyPRC TransfusionLaboratories check (LFT, Bili direct, indirect, etc)Abdominal & Obstetric USG
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Complete Blood CountDate : 21/02/2015
NormalValuesSGOT:43 P
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Complete Blood CountDate : 21/02/2015
NormalValuesAlkali Phos:1010 74-311Gamma GT:523P
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Follow upDate : 2402/2015S : Abdominal pain, Menstruation(-)O : VS : TD 110/60 N 88 RR 19 Temp : 36,2Anemic -/-, Icteric +/+Abdomen : No clinical changesLab : Hb 10,9A : Obstructive Icterus + Abdominal pain due to suspect gallstones, DD : Cholecystitis + Secondary amenorheaP : Continue existing TherapyAlbumin TransfusionObstetric USG
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Follow upDate : 26/02/2015S : Abdominal pain, Menstruation(-)O : VS : TD 110/60 N 88 RR 19 Temp : 36,2Anemic -/-, Icteric +/+Abdomen : No clinical changesLab : Hb 10,9A : Obstructive Icterus + Abdominal pain due to suspect gallstones, DD : Cholecystitis + Secondary amenorheaP : Continue existing TherapyAbdominal USGFeces laboratories exam
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Complete feces exam + blodDate : 29/02/2015
NormalValuesColor:Blackish green 74-311Consistency:normalP
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Follow upDate : 01/03/2015S : Abdominal pain, O : VS : TD 110/70 N 84 RR 18 Temp : 36,3Anemic -/-, Icteric +/+Abdomen : No clinical changesUSG : Multiple Cholelitiasis + Dilated intra & ekstra hepatic bile duct + Suspect Mass at Head of pancreasA : Obstructive Icterus + Abdominal pain due to multiple gallstones, DD : Cholecystitis + susp. Mass at Head of pancreasP : Continue existing TherapyMSCT abdomen
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Follow upDate : 02/03/2015S : Abdominal pain, Menstruation(-)O : VS : TD 120/70 N 82 RR 20 Temp : 36,2Anemic -/-, Icteric +/+Abdomen : No clinical changesMSCT : Intra & ekstra hepatic cholestasis + suspect Mass at duodenum (ampulla vateri) DD mass at head of pancreas A : Obstructive Icterus + Abdominal pain due to multiple gallstones + Secondary amenorhea + susp. Mass at duodenum (ampulla vateri) dd mass at head of pancreasP : Continue existing TherapyEndoscopy
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Follow upDate : 12/03/2015S : Abdominal pain, Menstruation(-)O : VS : TD 110/70 N 84 RR 18 Temp : 36,3Anemic -/-, Icteric +/+Abdomen : No clinical changesUSG : Multiple Cholelitiasis + Ascites + Suspect Mass at Caput pancreasA : Obstructive Icterus + Abdominal pain due to multiple gallstones, DD : Cholecystitis + Secondary amenorhea + susp. Mass at duodenum (ampulla vateri)P : Waiting for biopsy resultWhipple procedure surgery
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