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1. List of your hypothesis?

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!fter taking the history, you report this patient to the doctor in charge and you

e"amine this patient with him.

#n physical e"amination, you reveal that she is still conscious, but the temperature is$%.&°', (lood pressure ) *++ -+ mm g, and rapid shallow respirations.

The patient looks obese, but is slightly pale and perspiring. er sclera is icteric./ositive physical findings are confined to the abdomen. There is tenderness andrebound tenderness at the right upper abdomen, but no mass or organ is palpable. 0omuscular rigidity is found, but marked tenderness under the umbilical region,e"tending to the left midline.

She is then referred to the emergency unit.

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1. How has this ha!ge" your i"eas about Mrs. Fetty’s problem?

2. What further i!formatio! "o you !ee"?

Page #

!s she arrived to the emergency unit, the patient is placed at bed rest and the surgeon incharge put the patient in nil per oral and naso1gastric tube is inserted. Fluid resuscitation with

2inger 3actat solution and broad spectrum antibiotics are also administered. Meperidine wasgiven for pain control. 4rinary catheter is inserted and the urinary production is monitored.

The 3aboratory test results ) see laboratory pages

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No Register : 01901102007 Dokter :dr Kiki L, SpB-KBDNama Penderita : Ny etty !Lk"Pr# $% t& Po'i"R(angan : )*+Beda&No Rekap *edik : % 'amat : Bag Beda& Digesti

'amat : .' Bogor no % Band(ng /e'epon :

8/9/2019 Case3 Student 08

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Diagnosis"keterangan k'inis : Demam dan kter(s

No Pemeriksaan Metode Hasil Nilairujukan

Satuan

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emog'o in 1%,0 12,%-13,% g"dLLe(kosit 14 300 $$00-11

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! "IMIA "LINI" Bi'ir( in tota' 3,4 < 1,0 mg"dLBi'ir( in dire;t %,8

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'amat : @' Bogor no % Band(ng /e'epon :

Diagnosis"keterangan k'inis : Demam dan kter(s

No Pemeriksaan Metode Hasil Nilai

rujukan

Satuan

# $%INE %$TINBerat .enis 1,018 1,002 - 1,030

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& Pemeriksaan'eses

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Se'esai tg' 19"11"2007 Band(ng, 19 No?em er200719 %% 27 Pemeriksa,

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1. What is your impressio! ?

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!bdominal imaging is conducted)

/lain !bdominal 51ray) 0o calcifications noted in the kidney, gall bladder, or pancreas. Small bowel andtransverse colon are slightly distended, compatible with mild paralytic ileus.

epato1biliary1gallbladder ultrasonography)6ilatation of the gall bladder with thickening of the wall containing multiple stones.2eveals stones in the distal common bile duct, accompanied by biliary duct dilation.The pancreas is slightly edematous, but no fluid collection e"ists surrounding the

pancreas.

Magnetic 2esonance 'holangio1/ancreatography)Filling defects in the gall bladder and biliary tract.

7ndoscopic 2etrograde 'holangio1/ancreatography )Stones at the ampulla of 8ater, common bile duct, and gall bladder. Sphincterotomyand biliary drainage are done.

!dditional tests)Faeces ) microlith e"ist

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Page %

!fter two days of supportive treatments and 72'/, Mrs Fetty9s condition is improving.The surgeon in charge performs surgery on the third day of her admission.

!t the time of surgery, a cholecystectomy and common bile duct e"ploration are performed. The pancreas is also e"plored. The gall bladder shows signs of acute andchronic inflammation, and contains multiple stones, varying in si:e from ;.+ cm indiameter to less than * mm. #ne medium si:e stone and several very small stonesare recovered from the common duct. !ll the stones are cleared and a T1tube is left in

placed. !t the end of the operation, an operative cholangiogram shows the common ductto be free of stones. The pancreas is edematous but no signs of saponifications.

The surgeon tells Mrs. Fetty that she suffered from 'holangitis with acute pancreatitis dueto choledocholithiasis owing to cholelithiasis with cholecystitis.

er post operative course is uneventful and she remains free of symptoms.