2. Patient identification
Name : FM
Gender : Female
Age : 54
Race : Malay
Marital status : Married
Address : Terengganu
Occupation : Librarian
History taken from patient
Date of admission : 20/9
Date of clerking : 21/9
Date of discharged : 23/9
3. History taking
Chief complaint
She is admitted due to vomiting food after
eating and epigastric pain with burning
sensation for one week.
4. History of Presenting Illness
She was apparently well until 1 week ago.
Epigastric pain
• Site – epigastric region
• Onset – Sunday
• Character – colicky, burning, pain on touching, no
awakening in night due to pain
• Radiation – no
• Alleviating factor – no
• Timing- after eating
• Exacerbating factor – no
• Pain score – 8/10
5. Associated symptoms
• Dyspepsia
• Tea colour urine
• Yellow discolouration of eyes
• Non pale stools
• No fever but feeling cold
• Loss of appetite
• Dizziness
6. Review of systems
• CNS – dizziness, long sightedness
• RS – no shortness of breath
• CVS – no chest pain
• US – no dysuria, incomplete bladder emptying
• MSK – no muscle weakness, bone pain
7. Past gynecological history
• Menarche at 13 years old
• Now already menopause at 47 years old
• Previously regular menses with regular period
(7 days)
8. Past medical history
• Hypertension – for 6 years, currently on
medication (atenolol)
• No diabetes mellitus
9. Past surgical history
• No surgery done before
• She was admitted to surgery ward in
September 2012 for acute cholecystitis. She is
discharged with antibiotics but need to follow
up under surgery clinic.
• She had back pain and now feeling well after
follow up with physiotherapist
11. Drug history
• Currently on anti-hypertensive medication
• No taking any supplement or traditional
medicine
12. Family history
• Her mother is still alive
• Her father has Parkinson disease and passed
away
• Her mother has hypertension and diabetes
mellitus
• Her 5 children all are healthy
• No family history of malignancy
14. GENERAL EXAMINATION
INSPECTION
On general inspection, a 54 years old Malay lady was lying comfortably in
supine position. She looked well, not in pain and not in respiratory distress.
The patient was alert and conscious regarding the place, time and person.
Hydrational status and nutritional status was clinically adequate. No any
gross deformity and abnormal involuntary movement found. There was a
cannula attach to her right dorsum of hand.
Vital sign:
Temperature(°C) : 37
Systolic blood pressure(mmHg) : 148
Diastolic Blood Pressure(mmHg) : 94
Pulse Rate (/min) : 65
Respiratory rate (/min) : 20
15. 1. Upper limbs
a) Palms – moist, warm and pink in colour. No palmar erythema
b) Fingers and Nails – no peripheral cyanosis, no clubbing, no leuconychia, and
no koilonychia
c) Pulse rate -- 65 beats per minute with good volume and regular rhythm.
d) Respiratory rate was 20 breath/ min.
e) Forearm and arm – no scratch mark and bruises are found
f) Blood pressure – 148/94mmHg.
g) No flapping tremor present.
2. Head
a) Eyes- yellowish discolouration of sclera and conjuctiva was pink in
colour.
b) Mouth and tongue – moist , no any redness, no enlargement of
tonsil, no glossitis and no angular stomatitis. There was also no
central cyanosis. Uvula was centrally located
c) Oral hygiene was satisfied. There was no any discharge found at
both ears.
16. 4. Chest wall and axilla
No spider naevi present.
5. Lower limbs
No pitting edema, posterior tibialis and dorsalis pedis pulse was felt.
3. Neck
There is no any enlargement of submental, submandibular, cervical and
supraclavicular lymph node.
17. Specific examination of the abdomen :
1. Inspection
On inspection the abdomen was slightly distended and
symmetrical in shape.
Abdomen move with respiration.
The umblicus was centrally located and inverted.
No any surgical scars,
No prominent or dilated vein,
No skin discolouration,
No visible peristalsis,
No visible pulsation.
No coughing impulse present means that the orifice are
intact.
18. 2. Palpation and percussion
On superficial palpation, there was tenderness at epigastric
region.
On deep palpation , there was no any palpable mass found.
Liver
The liver span was 9cm. Hepatomegaly was absent.
Spleen
Absent of splenomegaly. Troube space was resonance.
Murphy’s Sign
Absent
Left and right kidney
Not ballotable
Shifting dullnes
Negative
19. 3. Auscultation
Bowel sound
Present of 4 bowel sound per minute
Renal bruits
Absent
The patient refused to undergo PR and external genitalia examination.
There is no enlargement of Virchow’s gland.
20. Provisional diagnosis
• Cholelithiasis
=Supporting points from history
-epigastric pain
-tea coloured urine
-yellow discolouration of sclera
-pain appears after having meal
-vomiting
=Supporting points from physical examination
-tenderness at epigastric region
23. Laboratory
PROTHROMBIN TIME/ ACTIVATE PARTIALTHROMBOPLASTIN
CODE RESULT UNIT TYPE STATUS REFERENCE
RANGE
PT 11.3 SECOND 10.6 – 15.0
PTRatio 0.84
INR 0.79
APTT 72.7 SECOND HIGH 29.0 – 40.0
APTTRatio 2.2
24. LIVER FUNCTION TEST
CODE RESULT UNIT TYPE STATUS REFERENCE
RANGE
TOTAL
PROTEIN
77 g/L 66 - 83
ALBUMIN 44 g/L 35 - 52
GLOBUIN 33
A/G Ratio 1.3
ALP 125 U/L HIGH 30 - 120
ALT 348 U/L HIGH <45
TOTAL
BILIRUBIN
85.5 Umol/L HIGH 5.0 – 21.0
28. Ultrasound
• Liver is normal in echogenicity and echo
texture. Liver surface are smooth and focal
lesion seen. Gall bladder is not well distended
as patient is not fast. However multiple calculi
are seen within the gall bladder. Largest of
which measures 1.3 cm. Portal vein and
common bile duct are not dilated. No
intrahepatic biliary tree dilation. Visualized
pancreas is normal. Spleen is normal
measuring 8.4 cm. Conclusion : cholelithiasis
29. Management
21/9/13 She is given metronidazole,
azithromycin, paracetamol, vitamin K, atenolol.
23/9/13 (date of discharged) She is given
chlorpheniramine maleate and metronidazole
for 1 week course.
