1. Patient’s Details
Name: Muzakir
Age: 28
Registration No: 1399683
New I.C No: AR214683
Race: Indonesian
Sex: Male
Chief complaint: Abdominal Pain
Date of Admission: 20th October 2013
History of Presenting Illness
Patient presented with abdominal pain which started at the right hypochondriac region and
radiates to the epigastrium. Pain started about a week prior to admission. The pain is described as
sharp pain at the right hypochondriac region, and burning pain at the epigastric region. There
were no alleviating and aggravating factors. The pain becomes worst 3 days prior to admission.
The pain score was 8 to 10. Patient went for a GP visit at KlinikKesihatanPandamaran when first
noticed the abdominal pain. Doctor diagnosed as gastritis and was given antacids. Pain resolved
for a while but the pain recurred.
Patient also complaint of vomiting for 2 days prior to admission. He vomited for 3 to 4 episodes
per day post prandially. Vomitus contains food particles and fluid. Patient claimed there is no
blood in the vomitus.
Patient also had fever associated with chills and rigors. Fever started after the abdominal pain
manifested. The fever was intermittent for about a week.
Patient claimed there was no tea coloured urine, no itchiness, and no dysuria.
Past Medical History
Patient was diagnosed with gastritis one year ago. Other than that, he has no hypertension, no
diabetes mellitus and no history of asthma.
Past Surgical History
Patient had never undergone any surgical interventions.
Drugs and Allergy History
Patient has no known drug allergy and also no known food allergy. He is also not on any
medications prior to admission.

2. Family History
There are no family history of hypertension and diabetes. There is also no known history of
malignancy. Patient’s father passed away when he was a child, hence he could not establish the
cause of death. Patient’s mother is currently alive and well.
Social History
Patient is staying with brother at TelokPanglima, Klang. He is married 5 months ago. Patient has
been in Malaysia since 2006 and last went back 5 months ago. He is a smoker. Smoked 5 to 6
sticks per day since 8 years ago. Patient claimed that he never consumed alcohol. He works at a
‘kedairuncit’ with income of RM 800 per month.
Systemic Review
Cardiovascular system
He has no chest pain, no palpitations and no claudication.
Respiratory system
He has no shortness of breath, no cough, and no dyspnoea.
Genitourinary system
He has no frequency, no dysuria, no hesitancy no incontinence and no nocturia.
Neurological system
He has no headache, no visual disturbances, and no speech disturbances.
Summary of History
A 28 years old, Indonesian male came to casualty with chief complaint of right hypochondriac
pain which radiates to epigastric region for about a week prior to admission. Pain was associated
with fever for a week and also vomiting for 2 days prior to admission. He also has a history of
gastritis for one year.
Physical Examination Findings
Muzakir was alert and conscious. He was resting comfortably on his bed. He was not in
respiratory distress. He is not drowsy, not confused and not disoriented. Upon general inspection,
he has fair hydration status, there is no muscle wasting, he is on 5% Dextrose intravenous drip
attached to his left forearm. He is also on continuous bladder drainage.There is presence of tea
coloured urine.

3. Upon general examination, he has no clubbing, no leukonychia, no koilonychias and he has no
palmar erythema. There are no scratch marks, and also no bruises. There was no flapping tremor.
He has no conjunctiva pallor. There is presence of mild sclerotic jaundice.He has good oral
hygiene. There is no glossitis, and no angular stomatitis. There is no spider naevi, no loss of
axillary hair and also no gynaecomastia. There is also no pitting oedema. His vital signs were as
follow:
Temperature: 36.8oC
Blood pressure: 96/69 mmHg
Pulse: Rate: 64 beats/min
Rhythm: Regular
Volume: Good
Respiratory rate: 14 breaths/min
Upon specific examination of the abdomen, the abdomen is scaphoid, symmetry and move with
respiration. The umbilicus is centrally located and inverted, there is no surgical scars, no
prominent dilated veins, no skin discoloration and there is negative cough impulse. There is no
supraclavicular lymph node enlargement.There is tenderness at right hypochondriac upon
superficial palpation. There is no guarding and no rebound tenderness. Upon deep palpation
there is tenderness at epigastric region and also at right hypochondrium. There are no
palpable mass, and no palpable solid viscera. The liver measured about 6.5 cm. the spleen and
kidney was not palpable. Murphy’s sign was negative and there is no shifting dullness. The
bowel sounds were present and normal intensity. There were no renal bruits heard.
Upon digital rectal examination reveals brownish stool and there is no presence of blood.
Respiratory system
The patient was not coughing nor did he have wheezing or stridor. On inspection of the chest and
back, no scars, deformities or prominent veins were seen. Chest expansion was symmetrical on
both sides. Breath sounds were vesicular and of equal intensity in all lung fields.
Cardiovascular system
Apex beat was not visible. No abnormal pulsation was seen. On palpation the apex beat was
normal in position and character. No thrills or abnormal pulsations were felt. S1 and S2 were
heard in normal density, no pathological splitting heart sounds and there was no murmur.

4. Central Nervous system
On inspection, there was no muscle wasting or fasciculation noted. Both upper limbs have
normal tone with no clonus. All the muscle power was 5/5 with normal reflexes bilaterally.
There was also no loss of sensation of both upper and lower limbs. His cranial nerves were
intact.
Diagnosis
Provisional diagnosis
Ascending cholangitis
Reason:
Patient’s condition fulfills the Charcot’s triad which is right hypochondrium pain,
pyrexia and jaundice.
Cholecystitis
Reason:
Presentation for cholecystitis is right hypochondrium to epigastric pain, vomiting
and also associated with fever.
Differential diagnosis
Gallbladder empyema
Reason:
Perforated peptic ulcer
Reason: patient presented with a sudden onset epigastric pain, which is the presentation for
perforated peptic ulcer disease. Patient also has a history of gastritis for one year. However, there
is no history of NSAIDs usage, no history of melena, no hematemesis, and no hematochezia
making the diagnosis to be unlikely in this patient.
Liver abscess
Reason:
Fever, epigastric pain and also jaundice can be the presentation for liver abscess.
However, in abdominal physical examination there are no palpable mass making
it unlikely in this patient.
Basal pneumonia
Reason:
Patient has fever and vomiting which are symptoms of basal pneumonia.
However, there is no shortness of breath and no coughing which makes basal
pneumonia unlikely in this patient.

5. Acute diverticulitis
Reason:
Vomiting and severe pain in right hypochondrium and epigastric region are
common presentation of acute transverse colon diverticulitis. If abscess
developed, systemic presentation like pyrexia would manifests. However, patient
would also complain of changes in bowel habits. Since there are no changes in
bowel habits in this patient, the diagnosis is most unlikely in this patient.
Investigations
Full blood count
Hemoglobin concentration 14.7g/dL
Total White Blood Cell 19.25×10^9L
Platelets 245×10^9L
Hematocrit 43.2%
Comment:
Patient’s haemoglobin concentration is within normal range which is 13-18g/dL.
White blood cell count is elevated, suggesting there is an infection. The platelets
count is within normal range which is 150-400×10^9L. The hematocrit level is
also within normal range which is 40.7-50.3%
Liver function test
Albumin 45g/L
Alkaline phosphatase 271iU/L
Alanine transaminase 275iU/L
Total bilirubin 91.1µmol/L
Comment:
Patient’s albumin level is within normal range which is 38-50g/L. His ALT is
markedly elevated compared to normal range which is 5-35iU/L. His ALP level is
also elevated compared with normal range, which is 30-150iU/L. His total
bilirubin level is significantly elevated compared to the normal range which is 317µmol/L.
Renal function test
Sodium 134mmol/L
Chloride 96mmol/L
Urea 29mmol/L
Creatinine 90 µmol/L

6. Comment:
His sodium and chloride level is slightly lower compare to normal which is 135145mmol/L and 98-107mmol/L respectively. His urea level is significantly
elevated compared to the normal range which is 2.5-7.5mmol/L. The increase in
urea level suggests that the patient is dehydrated. This is probably due to
vomiting. The creatinine level is within normal range which is 70-130µmol/L.
Blood gas
pH 7.41
PaO2126.0 mmHg
PaCO2 34.7 mmHg
Base excess -1.9mmol/L
His pH level is within normal range which is 7.35-7.45.
Chest X-ray
No air under diaphragm. Thereis no airspace opacity, lobar consolidation, or interstitial opacities.
Ultrasound Hepatobiliary system
Liver is homogenous with regular margin and normal echotexture. No focal liver lesion.
Dilatation of proximal common bile duct and both intra hepatic ducts 2o to common bile duct
stone measuring 1.2×1.4×2.0 cm.
Portal vein is patent.
Gallbladder is distended with presence of gallbladder sludge within.
Gallbladder wall is not thickened and there is no pericholecystic fluid collection.
Spleen and pancreas is normal.
Conclusion of ultrasound hepatobiliary system; proximal choledocholithiasis causing biliary
obstruction.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
ERCP findings: Dilated common bile duct with multiple stones.
Post ERCP diagnosis: Choledocholithiasis. Several stones seen. One large stone was removed
and several remained.