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CASE

REPORT
Friday, March 13th 2015
Advisor
Dr. Dompak S. H, Sp. Rad
Resident

Dr. Radityo Budi L (DIT)


A.W.S General Hospital
SAMARINDA

Adm. Date : 21/02/2015


Na
Fema
:Ny. H Sex :
me
le
Age :31 yo MR :

Chief
complain

: Pain at right Upper abdomen

Hystory
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
2

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

: Suspect Obstructive Icterus +


Abdominal pain due to suspect
Gallstones
DD : Cholecystitis

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

Complete Blood Count


Date : 21/02/2015

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

Complete Blood Count


Date : 21/02/2015
Alkali
Phos
Gamma
GT
Anti Hbs
Anti HCV
PP test

: 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

Complete feces exam + blod


Date : 29/02/2015
: Blackish green
Color
Consisten
: normal
cy
: Negatif
Blood
Mucus
Ocult
blood

: 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

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