CASE WRITE UP 2

SURGERY POSTING

NAME

: NOOR HAZIRAH BINTI NOOR AZHARI

GROUP

: 5A

YEAR

: 5 (2015/2016)

MENTOR : ASSOC. PROF. DR. WONG SEAK KHOON

PATIENTS DETAILS:
Name

: Mrs. Noraznin Asbaha binti Mohd Ali

Age

: 48 years old

Race

: Malay

Gender

: Female

Address

: Tanjung Rambutan, Ipoh

Occupation

: Kindergarden teacher

Status

: Married

Date of admission

: 28th September 2015

Reg. Nu

: HRPB 175009

CHIEF COMPLAINT
Patient came to the hospital with the chief complaint of cough for 2 months, fever and upper
abdominal pain for 1 month prior to admission.
HISTORY OF PRESENTING ILLNESS
Mrs. Noraznin had underlying diabetes mellitus for 9 years (she was on insulin), and a
history of right breast abscess 4 years ago (Incision and Drainage had been done). She was
apparently well until 2 months ago, she developed cough which was intermittent and
productive in nature, associated with whitish sputum with no blood-stained or coughing out
blood (haemoptysis). The cough get severe at night and disturb her sleep. She also had chest
pain when she cough. Other than that, she did not had any fever, headache, muscle pain or
weakness, shortness of breath or abdominal pain at this time.
After 1 month of cough, she suddenly developed fever which was on and off, associated
with chills, rigors, night sweat and runny nose. At the same time, she started to have upper
abdominal pain, particularly at the right side (right hypochondrium). The pain was sudden in
onset, cramping and continuous in nature, non-colicky, did not radiated to any parts of the
abdomen, tip of the shoulder or to the back. It was aggravated by coughing and relieved by
rest. The pain score was about 7/10. Moreover, she also had lethargy and loss of appetite,

when she only ate half portion of the meal she usually had. Her weight also reduced by 4kg in
these 2 months, but her abdomen became distended slowly.
However, she did not have any headache, blurry of vision, shortness of breath, muscle
weakness or numbness. She did not have any urinary symptoms; such as burning sensation or
abdominal pain during micturition, increase frequency to the toilet, feeling of rush to the
toilet or presence of blood in the urine. She did not realised any tea-colored urine or pale
stools. She did not have any vomiting or diarrhea. She did not complaint of pain after she eat
fatty meals or offensive, floated faeces on the water in toilet bowl. Moreover, she did not had
any history of going to hawker stalls, travelling abroad or any blood transfusion before. She
usually ate cooked food at home. She was not a smoker, non-alcoholic or did not abused any
drugs. There was no other family members had the same symptom as her. This is the first
time she was experiencing the symptoms.
In the period of illness, she had been brought to the Tanjung Rambutan Health Clinics for
2 times and to HRPB for 3 times. However, she was not admitted and only being prescribed
with paracetamol, medication for her cough and runny nose, and also antibiotics. However,
the symptoms was not relieved or improved.
Therefore, on 28th September 2015, due to worsening abdominal pain, she was then
brought to the emergency department of HRPB, Ipoh. The doctor noticed that she had a tinge
of yellowish discoloration of the sclera, and she had tea-colored urine and pale stools. Thus,
her blood was taken and IV drip was given. She was then admitted into the ward 2B. On
admission, she still had fever and cough, and looked in pain.
SYSTEMIC REVIEW
1) Respiratory system:
No shortness of breath
No yellowish or greenish sputum
2) Central nervous system:
No blurring of vision
No loss of consciousness
No headache
No loss of sensation.
3) Cardiovascular system:
No palpitation or excessive profuse sweating.
4) Gastrointestinal system
No constipation

 No diarrhea
5) Musculoskeletal system
No muscle pain
No joint pain
No muscle weakness
6) Genitourinary system
There is no increase in frequency of urination. (normally 2x per day)
No hematuria
No dysuria
No urgency of going to toilet.
PAST MEDICAL AND SURGICAL HISTORY

She had multiple admissions to the hospital before.

She had diabetes mellitus since 9 years ago and was on insulin.
She had right breast abscess on 2011; Incision and Drainage had been done.
She had three Caesarean Section done on 1996, 2000 and 2006. The reasons were
because of breech presentation of the foetus for the first two, and the third one was due to
the previous two caesaerian section.

DRUG HISTORY
She only took insulin for her diabetes mellitus. She had no drugs or food allergies.
FAMILY HISTORY
She did had family history of chronic medical illness such as diabetes mellitus, ischaemic
heart disease and asthma. No family history of hypertension or any malignancy.
MENSTRUAL HISTORY
She attained menarche at the age of 13 years old. She had 7 days of menstruation with regular
cycles of 28-30 days. She had no menorrhagia or dysmenorrhagia.
SOCIAL HISTORY
Mrs. Noraznin had married and blessed with 3 children. She works as a kindergarten teacher.
She was a non-smoker and non-alcoholic.

PHYSICAL EXAMINATIONS
GENERAL CONDITION
Mrs. Noraznin, 48 years old Malay lady, was lying down with one pillow, alert,
conscious, medium-built and she was not in respiratory distress. However, she looked in pain.
She wore her nametag on her left wrist and had branula on her right dorsum of the hand. Both
of her radial pulses were felt. Her palm looked pale and she had conjunctival pallor, a tinge of
scleral jaundice and also pitting edema up to the knee , capillary refill time was less than 2
seconds, no clubbing of fingers, no cyanosis, no palmar erythema, no leukonychia, no
koilonychia and no neck enlargement.
VITAL SIGNS
Pulse rate: 90 beats per minute, with regular rhythm and good volume. No radialradial delay, radial-femoral delay and collapsing pulse.
Blood pressure: 120/70 mmHg
Respiratory Rate: 20 breaths per minute.
Temperature: 37.5oC
HEAD AND NECK
a)

Inspection: No anterior and posterior neck swelling.

b) Palpation: No thyroid enlargement, trachea was not deviated. The cervical lymph node
was not enlarged.
c)

Auscultation: No thyroid and carotid bruit heard.

CARDIOVASCULAR SYSTEM
a)

Inspection: The chest is symmetry. There was no dilated vein noticed, suggesting no
superior vena cava obstruction. No pacemaker attached on his chest and no visible
palpitation.

b) Palpation: Apex beat can be felt at the 5th intercostal space at mid clavicular line. There
was no parasternal, pulmonary, and aortic heave or thrill. All the peripheral pulses were

palpable.
c)

Auscultation: 1st and 2nd heart sound was heard at all mitral, tricuspid, pulmonary and
aortic area. No gallop rhythm or murmur heard.

RESPIRATORY EXAMINATION
a)

Inspection: The chest is symmetry. There was no scars, dilated veins and nodules. The
chest moved with respiration.

b) Palpation: Trachea is not deviated. Apex beat can be felt. The chest movement and
expansion is symmetry. The tactile fremitus equal on both sides.
c)

Percussion: There is resonance upon percussion at both chest.

d) Auscultation: She had reduced air entry at the right lower lobe of the lungs. Otherwise,
vesicular breath sound was heard with no added sound.
ABDOMINAL EXAMINATION
a)

Inspection: The abdomen was distended, and it moved with respiration. The umbilicus is
in the midline. There was caesarean section scar which was well-healed, no dilated veins

and no visible peristalsis. There is also no bruises or rashes.

b) Palpation: The abdomen was soft. There was tenderness at the epigastric and right
hypochondriac region of the abdomen, with no mass palpable on superficial and deep
palpation. There was no guarding and no rebound tenderness. The liver was palpable
below the costal margin; soft, regular margin and tender. The liver span was 16 cm. The
spleen are not palpable. Both of the kidneys are not ballotable.
c) Percussion: Abdomen was dull on percussion at the flank. Shifting dullness was positive.
d) Auscultation: The normal bowel sound is heard and there is no renal bruit.
e)

Normal genitalia noted. Femoral pulse was palpable and there was no enlargement of the
inguinal lymph node.

f)

Per rectal examination shows that the rectum is empty. No stools or blood noted.

LYMPHATIC SYSTEM EXAMINATION

No enlargement of lymph node at ingunal area, femoral area and axillary lymph nodes area.
CENTRAL NERVOUS SYSTEM EXAMINATION
a)

Higher Mental status : Patient was conscious and alert with the surrounding. She was
able to talk and respond to the questions that being asked. She was aware with her
diseases and also stable.

b) Cranial nerves
Cranial nerves
Olfactory nerve
Optic nerve

I
II

Impression
She can smell the fragrant
Visual field was normal.
Visual acuity was normal.
Pupillary reflex was intact.

III, IV, VI
V

Occulomotor, trochlear,

Fundoscopy was not done.

There was no diplopia, strabismus or nystagmus.

abducens nerve
Trigerminal nerve

Sensory: She can feel as the cotton wool applied at

the maxillary area.
Motor: There was masseters muscle wasting.

VII

Facial nerve

Corneal reflex was intact.

Her face was symmetrical when he smiles, frowned

VIII
IX
X
XI

Vestibulocochlear nerve
Glossopharyngeal nerve
Vagus nerve
Accessory nerve

her forehead, and closed her eyes tightly.

She could hear whispering sound made.
Uvula is at the center and was not deviated.
Gag reflex was positive
She could shrug her shoulders and resisted my

Hypoglossal nerve

resistance.
She could push her tongue against her cheek and

XII

resist my movement against it.

c)

Motor system:
Inspection = She had no muscle wasting, any fasciculations or abnormal movement
in the upper and lower limb.
Palpation = Her muscle bulk felt flabby and non-tender.
The muscle tone and power was normal

d) Sensory system: The sensory system was normal

e)

Reflexes
Reflexes
Jaw jerk
Biceps
Triceps
Supinator
Knee
Ankle
Plantar

Left
Present
Present
Present
Present
Present
Present
Present

Right
Present
Present
Present
Present
Present
Present
Present

f)

Cerebellar sign- she has no cerebellar signs

CLINICAL SUMMARY
Mrs. Noraznin, 48 years old, Malay lady, with underlying diabetes mellitus for 9
years; on insulin and a history of right breast abscess with the management of incision and
drainage on 2011, came to the emergency department of HRPB with the complaint of
productive cough with whitish sputum for 2 months which disturbed her sleep as it worsened
at night, and also fever associated with runny nose and upper abdominal pain for 1 month
prior to admission. It was intermittent pyrexia, with chills, rigors and night sweat. The upper
abdominal pain was particularly at the right hypochondrium, sudden, cramping, non-colicky,
not radiated to anywhere and persistently there. It was aggravated by coughing and relieved
by rest. The pain score was about 7/10. Moreover, she also had lethargy, loss of appetite and
loss of weight.
However, she did not have any headache, blurry of vision, shortness of breath, muscle
weakness or numbness. She did not have any urinary symptoms and she did not realised any
symptoms of jaundice at home. She did not have any vomiting or diarrhea. She did not
complaint of pain after she eat fatty meals or offensive, floated faeces on the water in toilet
bowl (symptoms of chronic cholecystitis). Moreover, she did not had any history of going to
hawker stalls (no contaminated food), travelling abroad or any blood transfusion before. She
usually ate cooked food at home. She was not a smoker, non-alcoholic or did not abused any
drugs. There was no other family members had the same symptom as her. This is the first
time she was experiencing the symptoms.
From the physical examination, she looked in pain, and she had pale palm, conjunctival
pallor and a tinge of scleral jaundice. She also had pitting edema up to the knee and on
abdominal examination, her abdomen was distended due to ascites, there was tenderness at

epigastric and right hypochondriac region, positive shifting dullness, tender hepatomegaly
and splenomegaly. She also had reduced air entry on auscultation at the right lower lobe of
the lungs.
PROVISIONAL DIAGNOSIS
Liver Abscess: She had underlying diabetes mellitus which shows that she had
immunocompression, that is a risk factor of having liver abscess. Plus, intermittent fever with
chills and rigors and significant right hypochondriac pain which was sudden, cramping and
persistently there for 1 month; shows that it was a chronic disease. She also had some signs of
stigmata of liver disease; jaundice, ascites, pitting edema and hepatosplenomegaly.
DIFFERENTIAL DIAGNOSIS
1.

Chronic cholecystitis

Patient was presented with 1 month of upper abdominal pain, particularly at the right
hypochondriac region. She also fit with the 5Fs; female, fat, fertile, forty and fair. She also
had a tinge of jaundice.
2.

Chronic pancreatitis

Patient was presented with 1 month of upper abdominal pain, particularly at the right
hypochondriac region which was persistently there. She also had weight loss and jaundice.
3.

Chronic Hepatitis

Patient was presented with 1 month of upper abdominal pain, particularly at the right
hypochondriac region. She also had hepatomegaly with jaundice.
INVESTIGATIONS
Based on the provisional and differential diagnoses, I would like to suggest a few
investigations in order to diagnose Mrs.Noraznins disease.
1.

Full blood count: To investigate the haemoglobin level and identify the severity of her
anaemia. I also wanted to know the white blood cell count; if there is leucocytosis, it may
suggest infections.

2.

Venous blood gases (VBG): To investigate the acid-base status of the patient.

3.

Abscess Sample Culture and Sensitivity: To investigate the organism which caused the

abscess/infection.
4.

Coagulation Profile: To confirm normal clotting function before undergoing any

procedures or operation.

5.

Renal Profile: To investigate the kidney function and to investigate any electrolyte
imbalance.

6.

Liver Function Test: To investigate the function of the liver or any liver problem.

7.

Urine FEME (Dipstick): To check any abnormality of the urine which may help with the
diagnosis.

8.

Serum Amylase: To investigate the exocrine function of pancreas.

9.

Blood Screening Test: To exclude any hepatitis or HIV diseases.

Imaging
1.

Ultrasound of the Abdomen: To investigate if there is any liver abscess, tumour or

gallstones in the liver or gallbladder.

2.

CT Scan of the Thorax, Abdomen and Pelvis: To investigate further about the liver
abscess and to detect any other problem to other parts of the body.

Below are the results from the investigations done in the hospital:
1) Full blood count (FBC):
COMPONENT
White blood cell
Haemoglobin
Haematocrit
MCV
MCH
MCHC
RDW
TRBC
Platelets
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
MPV

RESULTS

NORMAL VALUE

UNITS

INTERPRETATION

17.2
9.1
29.5
81.1
25.0
30.8
22.8
3.64
245
83.03
10.94
4.82
1.04
0.17
6.6

0-11.0
13.0-18.0
40-52
76.0-96.0
27.0-32.0
30.0-35.0
13.0-14.4
5-6.5
150-400
40-75
20-45
2-10
1-6
0-1
7.4-10.4

109/L
g/dL
%
FL
PG
g/dL
%
1012/L
109/L
%
%
%
%
%
FL

High
Low
Low
Normal
Low
Normal
High
Low
Normal
High
Low
Normal
Normal
Normal
Low

Impression: The blood results revealed leucocytosis (with neutrophilia and lymphopenia),

and normochromic microcytic anaemia which indicates there was acute infection and
anaemia.

2) Venous Blood Gas (ABG)

COMPONENT

RESULTS

NORMAL

UNITS

INTERPRETATION

Blood pH
CO2 pressure
O2 pressure
Bicarbonate Actual,

7.453
32.30
35.5
22.10

VALUE
7.35-7.45
35-45
80-100
21-25

mmHg
mmHg
mmol/L

High
Low
Low
Normal

HCO3
Base Excess
O2 Saturation
Total CO2

-1.90
71.4
19.2

-3 - 3.0
95-98
22.0 - 26.0

mmol/L
g/dL
mmol/L

Normal
Low
Low

Impression: It shows that patient was having respiratory alkalosis, with high pH, low PaCO2
and normal bicarbonate, which may be due to hyperventilation.
3) Abscess Sample (from the liver) Culture and Sensitivity
COMPONENT
Microscopic Examination

RESULT
White cell: Few
Positive cocci: Nil
Positive bacilli: Nil
Negative cocci: Nil
Negative bacilli: Few
Yeast cell: Nil
Epithelial cell: Nil
Isolate
Klebsiella pneumoniae
Ampicillin
Resistant
Amoxicillin/Clavulanic Acid
Susceptible
Cefuroxime
Susceptible
Trimethoprim/Sulfamethoxazole Susceptible
Impression: The cause of patients liver abscess was infection by Klebsiella pneumoniae.
4) Coagulation profile:

COMPONENT RESULT
NORMAL VALUE
Prothrombin
15.0
9.57-12.09
time
INR

1.17

INTERPRETATION
High

2.0-2.5 (probable VT
and smoking)
2.0-3.0 (DVT, TIA,
AF)
3.0-4.5 (recurrent

Activated

DVT)
28.8 - 45.3

44.3

Normal

partial
thrombin time
Impression: Prothrombin time is high which indicates the blood is clotting slowly. It may be
due to Vitamin K deficiency because of liver problem.
5) Renal profile:
COMPONENT

RESULT

NORMAL

UNITS

INTERPRETATION

2.6
129
3.7
88
40

VALUE
1.7-8.3
136-145
3.5-4.5
98-107
62-106

mmol/L
mmol/L
mmol/L
mmol/L
umol/L

Normal
Low
Normal
Low
Low

Urea
Sodium
Potassium
Chloride
Creatinine

Impression: The result for renal profile shows that sodium, chloride and creatinine was low.
This indicates that there was fluid electrolytes imbalance which maybe caused by liver
problem.

6) Liver Function Test:

COMPONENT

RESULT

NORMAL

UNITS

INTERPRETATION

Total bilirubin
Alkaline Phosphatase
Albumin
AST
Alanine Transaminase
Globulin

52.1
553
22
35
18
28

VALUE
1 - 17.1
35-104
35-52
0-32
0-33
-

umol/L
U/L
g/L
U/L
U/L
g/L

High
High
Low
High
Normal
-

Impression: The liver function test shows that there was increased total bilirubin level which
was the reason Mrs. Noraznin was having jaundice. Moreover, her liver enzymes (ALP and
AST) were high which shows hepatocellular problem. Her albumin were low which indicate
why she was having ascites and pitting edema.
7) Urine FEME (Dipstick)
COMPONENT
Glucose, urine
Urine Ketone Bodies
Nitrite
Leukocytes
Blood in urine
Bilirubin, urine
Protein, urine
Urobilinogen
Color
Clarity
pH, urine
Urine Specific Gravity

RESULT
Normal
+
Negative
Negative
Negative
1+
1+
2+
Dark Yellow
Slightly turbid
5.5 (Low)
>1.025 (High)

8) Screening Test

9)

COMPONENT
HbsAg Screening

RESULT
Non-Reactive (Chemiluminescent

Hepatitis C Antibody Screening

method)
Non-Reactive (Chemiluminescent

COMBO Test for HIV Screening

method)
Non-reactive

Serum

Amylase
COMPONENT RESULT NORMAL VALUE
INTERPRETATION
Amylase
16
28-100
Low
Impression: It may reflect impaired exocrine-endocrine relationship in the pancreas which
correlates with the patients condition of diabetes mellitus.
10) Ultrasound of the Abdomen: There is increase in liver span, measuring 16.2 cm.
Multiloculated and multiseptated hypoechoic lesions are seen in the right liver lobe,
some with echogenic debris within. The largest locule is at segment 8 of liver,
measuring 5.5 x 6.7 cm. There is also small hypoechoic collection seen at the

subcapsular region, measuring 1.4cm in depth. The intahepatic and common bile
ducts are not dilated. Gallbladder is distended. No calculi or wall thickening. Spleen is
enlarged, measuring 15 cm. Minimal free fluid in the pelvis.
Impression: The liver lesions are likely liver abscesses with subcapsular extension and
splenomegaly.
11) CT Scan of Thorax, Abdomen, and Pelvis Results:
Hepatomegaly. Multiple locules of hypodense collection noted in right lobe of

liver, consistent with ultrasound finding of liver abscesses.

Mild splenomegaly. No focal splenic lesion seen.
Small right pleural effusion with consolidation of adjacent lung.
Final Diagnosis: Liver Abscess

Management of the Patient:

1) Ultrasound Guided Drainage of Liver Abscess
a) Multiloculated liver abscess noted. The largest locule of the abscess is identified at
segment VII/VIII.
b) Drainage is performed using aseptic technique
c) Drainage tube size 8 is inserted under ultrasound guidance. Patient is comfortable
throughout the procedure.
d) Noted pus aspirate from the drainage tube- sample taken.
2) Post-Drainage of Pus; Keep the drain until minimal amount or no blood coming out. Then,
do ultrasound to reassess, Give antibiotics (IV Cefuroxime)

DISCUSSION
During my Surgery Posting this year, from my observation, liver abscess case are quite
uncommon compared to cases such as acute cholecystitis or choledocholithiasis. Therefore,
once I clerked this case, my first impression of her right hypochondriac pain was acute
cholecystitis. However, when I finished clerking her, the symptoms were not quite fit with
acute cholecystitis because of its duration, persistent non-colicky pain, associated with fever
with chills, rigors, night sweat, lethargy, productive cough and runny nose.
Moreover, during physical exam, she had jaundice, was anaemic, had pitting edema and
also ascites. Tenderness was also revealed during palpation of the right hypochondrium and
during palpation of the liver. Her spleen was also enlarged. The symptoms and signs were
very likely to be liver abscess.
Then, the diagnosis of liver abscess was suggested after ultrasound of the abdomen had
been done for her. CT Scan of the thorax, abdomen and pelvis confirmed the diagnosis of
liver abscess and late feature of right pleural effusion.
Liver abscess may be caused by the parasitic organism; such as Entamoeba histolytica
which is endemic in many parts of the world like Indian subcontinent, Africa and parts of
Central and South America where there is substandard hygiene and sanitation that increase
the mode of infection via faecal-oral route. However, my patient is a kindergarten teacher,
lives in a good hygienic area, did not travelled to any endemic area before and usually eat
cooked food at home; which is unlikely for her to be infected with Amoebiasis.
However, because of her immunocompromised state; as she is a diabetic patient for 9
years and was on insulin, she is prone to get infection which may lead to liver abscess. She
had no trauma which lead to liver injury before. Nevertheless, she had undegone few

caesarean section before and right breast abscess on 2011 which may contribute to the
haematogenous spread of organisms which caused liver abscess. The common organism
which caused pyogenic liver abscess are Streptococcus mileri and Escherichia coli. For this
patient, aspiration of the pus from the liver for culture and sensitivity shows that it was
Klebsiella pneumoniae.
Thus, for the management of the patient, she would need to undergo ultrasound guided
drainage of the liver abscess. Because of her liver abscess was multiple and multiloculated,
she will need a few times of this procedure to drain out the pus. Moreover, she will also need
therapeutic antibiotics such as cephalosporin and metronidazole for the smaller abscess to
resolve. After the procedure, Mrs. Noraznins condition had very much improved. Her
jaundice and anaemia had resolved. And her pain had also reduced.
From this case, I have learned that it is important to go through the history and physical
exam before directly jumped to a conclusion. Liver abscess case may not be as common as
cholecystitis now but as a medical personnel, we should be aware that it may become
endemic in these region too. As such with cases like tuberculosis and rabies.
I also learned that liver abscess can be treated efficiently with drainage and antibiotics.
However, it is important for us to detect the disease early so that complications; such as liver
rupture can be avoided.