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REPORT
Friday, March 13th 2015
Advisor
Dr. Dompak S. H, Sp. Rad
Resident
Chief
complain
Hystory
taking
Physical Examination
Anemic +/+ Icteric +/+
Thorax : Within normal
limit
Abdomen :
Distended (-)
Tenderness (+) at RUQ,
Murphy Sign (+),
Hepatomegaly (+),
Tympanic
Bowel Sound (N)
Flank :
Flank pain -/-, Flank
mass -/-, CVA tenderness
LABORATORY
RESULT
Complete Blood Count
Date : 21/02/2015
WBC
: 10,2 x 103 / L
RBC
: 4,79 x 106 / L
HGB
: 7,9 g/dL
HCT
: 31,7 %
PLT
: 223 x 103 / L
BT / CT
: 200 / 900
Blood Sugar
: 95 mg/dl
Ureum
: 23 mg/dl
Creatinin
: 0,9 mg/dl
Complete
Urination Count
BJ
Ketone
Nitrit
Leuko
Hb/blood
:
:
:
:
:
Color
Purity
pH
Protein
Glucose
Billirubin
Urobilino
:
:
:
:
:
1.015
Thick
Yellow
Cloudy
6,5
+1
+3
: +2
LABORATORY RESULT
Epithel :
Leuco :
Erytro :
Silinde
:
r
Crystal :
Bacter
:
ia
Fungi :
+
1-2
0-1
-
WORKING
DIAGNOSIS
Management
: Therapy
IVFD RL 1500cc/24h
Inj. Ceftriaxone 1gr/12h
Inj. Anthrain 1gr/8h
Inj. Ranitidin 50mg/12h
Curcuma tab 3x1
Follow up
Date : 22/02/2015
S : Abdominal pain, Menstruation (-)
O : VS : TD 90/60 N 82 RR 18 Temp : 36,4
Anemic +/+, Icteric +/+
Abdomen : No clinical changes
Lab
: Hb 7,9
A : Obstructive Icterus + Abdominal pain due to suspect
gallstones, DD : Cholecystitis + secondary amenorhea + Anemia
P : Continue existing Therapy
PRC Transfusion
Laboratories check (LFT, Bili direct, indirect, etc)
Abdominal & Obstetric USG
Normal
Values
P <25 W
< 31
P < 41 W
< 32
SGOT
: 43
SGPT
: 28
Bili Direk
: 4,1
0-0,25
Bili Indirek
: 0,6
0-0,75
Bili total
: 4,7
0-1
Protein
Total
: 3,8
6,6-8,7
Albumin
: 1,5
3,2-4,5
Globulin
: 2,3
2,3-3,5
: 1010
: 523
: Negatif
: Negatif
: Negatif
Normal
Values
74-311
P<38,
W<25
Negatif
Negatif
Follow up
Date : 2402/2015
S : Abdominal pain, Menstruation(-)
O : VS : TD 110/60 N 88 RR 19 Temp : 36,2
Anemic -/-, Icteric +/+
Abdomen : No clinical changes
Lab
: Hb 10,9
A : Obstructive Icterus + Abdominal pain due to suspect
gallstones, DD : Cholecystitis + Secondary amenorhea
P : Continue existing Therapy
Albumin Transfusion
Obstetric USG
Follow up
Date : 26/02/2015
S : Abdominal pain, Menstruation(-)
O : VS : TD 110/60 N 88 RR 19 Temp : 36,2
Anemic -/-, Icteric +/+
Abdomen : No clinical changes
Lab
: Hb 10,9
A : Obstructive Icterus + Abdominal pain due to suspect
gallstones, DD : Cholecystitis + Secondary amenorhea
P : Continue existing Therapy
Abdominal USG
Feces laboratories exam
: Negatif
Eritrosit
: 8-10
Leukosit
: 1-2
CEA
: 4,19
Normal
Values
74-311
P<38,
W<25
Negatif
Negatif
: positif
<10
ng/ml
Follow up
Date : 01/03/2015
S : Abdominal pain,
O : VS : TD 110/70 N 84 RR 18 Temp : 36,3
Anemic -/-, Icteric +/+
Abdomen : No clinical changes
USG : Multiple Cholelitiasis + Dilated intra & ekstra hepatic bile
duct + Suspect Mass at Head of pancreas
A : Obstructive Icterus + Abdominal pain due to multiple
gallstones, DD : Cholecystitis + susp. Mass at Head of pancreas
P : Continue existing Therapy
MSCT abdomen
Follow up
Date : 02/03/2015
S : Abdominal pain, Menstruation(-)
O : VS : TD 120/70 N 82 RR 20 Temp : 36,2
Anemic -/-, Icteric +/+
Abdomen : No clinical changes
MSCT : 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 pancreas
P : Continue existing Therapy
Endoscopy
Follow up
Date : 12/03/2015
S : Abdominal pain, Menstruation(-)
O : VS : TD 110/70 N 84 RR 18 Temp : 36,3
Anemic -/-, Icteric +/+
Abdomen : No clinical changes
USG : Multiple Cholelitiasis + Ascites + Suspect Mass at
Caput pancreas
A : Obstructive Icterus + Abdominal pain due to multiple
gallstones, DD : Cholecystitis + Secondary amenorhea +
susp. Mass at duodenum (ampulla vateri)
P : Waiting for biopsy result
Whipple procedure surgery