I. Patients Identity Name Age Sex Religion Nationality Admission Date and Time Hospital Discharge Date II.

Present Medical Status a. History of Present Illness History was taken by Heteroanamnesis from patients parents on August 13 th 2012. Patient came to Immanuel Hospital with fever. A patient came with a fever she has had for a month. The fever was continuous and the patient's body temperature decreased after taking antipyretics. She experienced sweats without chills when the fever occurred. She went to a clinic in Duren Sawit area 19 days before the admission date due to a fever that caused her a seizure. Her eyes rolled upward during seizure that lasted 3-5 minutes before she finally fell asleep. While at the clinic, patient was given anticonvulsant and antipyretic medications through the anus. Later, she was sent to B.A. Hospital and treated there for 12 days. She continuously had fever with nausea. She vomited food 2-3 times, there was no mucus or blood. A watery stool also occurred 8 times a day consisting of feces without mucus or blood; the color looked pale. Patient lost her appetite during her stay in hospital. After 12 days, she was allowed to discharge because according to the pediatrician who treated her, she had a digestive infection. There was no work-up done in B.A. Hospital such as USG; only transfusion once due to patient's low hemoglobin level. A week after discharge, patient still had a continuous fever without flu or cough. According to her mother, her skin looked a bit yellow and her stomach seemed awry, the right side was bigger. Her defecation frequency was normal. However, the feces appeared to be greenish yellow and the urine looked like tea. :D : 1 year and 7 month old : Female : Moslem : Indonesian : August 11th 2012, 08.28 WIB :-

Examination Date and Time : August 13th 2012, 09.00 WIB

Previous Disease History: One month prior to this admission, patient had never encountered this situation. Family Disease History: No one in patient's family had experienced any kidney or liver disease, although the aunt and grandmother had high blood pressure. Allergy History: Birth history: At term. Weight: 2.700 gram. Height: 52 cm. Normal active movements. Breast-fed until date. Immunization History: Complete; the latest was for the measles when patient was 9 months old. b. Physical Examination General Appearance Consciousness Pulse Respiration Temperature Weight Height Nutritional Status Skin Eyes : Moderate : Compos Mentis : 120 x/minute, regular, strong, equal : 28 x/minute, normal pattern : 37 0C : 9.3 kg : cm : Normal : pale (-),icteric (-),cyanosis (-), normal turgor. : anemic conjunctiva -/-, icteric sclera -/-, pupil round, isochors 3mm, light reflex +/+ reactive Nose : normal

Neck Chest Cor Pulmo

: no lymph node enlargement, mass (-) : shape and movement simetric in both sides : nomal heart sound, reguler, shuffle (-) : VBS +/+, rales (-), wheezing (-) : : asymmetric, the RUQ seems bigger : normal bowel sound : tympanic : soft, distention (+), mass (+) a/r RUQ, mobile, cystic consistency, pain when palpate

Abdomen Inspection Auscultation Percussion Palpation

Anus-Rectum Inguinal and Genital Extremities

: normal : mass (-), hernia (-) : upper ext : edema (-) lower ext : edema (-)

Neurology

: normal reflexes and no neurological deficits

c. Work Up Laboratory Findings 10.08.2012 Blood :Hb Ht 8,8 gr/dL 28 %

L Tc BRC

11.200/mm3 440.000/mm3 76-110 mm/hr

12.08.2012 Blood :Hb Ht L Tc E MCV MCH MCHC 13,6 gr/dL 40,8 % 13.610/mm3 289.000/mm3 5,7 mil/mm3 71 fL 24 pg/mL 33 mg/dL

13.08.2012 Blood :Alkaline phosphatase 827 U/L AST ALT Na+ K+ Creatinine 758 U/L 84 U/L 135 mEq/L 3,8 mEq/L 0,6 mg/dL

Ureum

10 mg/dL

Blood glucose at random 83 mg/dL Protein : Total Protein Albumin Globulin Bilirubin : Total Conjugated Unconjugated 0,93 mg/dL 0,59 mg/dL 0,34 mg/dL 5,0 g/dL 2,1 g/dL 2,9 g/dL

Imaging Studies 11.08.2012 Abdominal CT-Scan (axial, coronal and sagittal views) with intravenous and oral contrast (20 cc of intravenous Omnipaque 300 + 200 cc of oral contrast) Liver : the right and left intrahepatic biliary ducts are extent, forming round tubulers. Gall bladder : enlarging, size : 8,54 x 6,47 x 9,04 cm, thickened wall. Extrahepatic

biliary ducts are extent, both common bile duct and cystic duct. Interpretation : Choledochal cyst type V (Carolis disease), suspiciously infected.

III.

Resume

IV.

Diagnosis Choledochal cyst type V

V.

Therapy PRC transfusion on August 11th 2012 Medications : 11.08.201 2 Ceftriaxone 2x250 mg i.v Sanmol 1 cth prn Metrofusin 2x25 mg iv Rhelafen IVF NaCl 0,9% 500 cc/24hr 12.08.2012 13.08.2012 14.08.2012

VI.

Follow-up 11 August 2012 S: Continuous fever (+) Nausea (-) Vomit (-) Loss appetite (+) Urine looked like tea Defecation (-) 12 August 2012 S: Continuous fever (+) Nausea (-) Vomit (-) Loss appetite (-) Urine looked like tea Defecation frequency was normal, the feces

O: HR : 120 x/minute T : 36,6 C R : 30 x/minute

appeared to be greenish yellow O: HR : 120 x/minute T : 36,7 C R : 30 x/minute

Eyes : anemic conjunctiva +/+, icteric Eyes : anemic conjunctiva -/-, icteric sclera sclera -/-, pupil round, isochors 3mm, light -/-, pupil round, isochors 3mm, light reflex reflex +/+ reactive Abdomen : Inspection : asymmetric, the RUQ seems bigger Auscultation : normal bowel sound Percussion : tympanic Palpation : soft, distention (+), mass (+) a/r RUQ, mobile, cystic consistency, pain when palpate Input Oral : 750 cc i.v : 490 Blood : 140 Input Oral : 900 cc i.v : 500 + 11 Blood : +/+ reactive Abdomen : Inspection : asymmetric, the RUQ seems bigger Auscultation : normal bowel sound Percussion : tympanic Palpation : soft, distention (+), mass (+) a/r RUQ, mobile, cystic consistency, pain when palpate

TOTAL : 1380 Output A: Observation Anemia P: Exploration of CBD Urine : P7x Vomit : Feces : Blood : A:

TOTAL : 1411 Output Urine : P8x Vomit : Feces : 1x Blood : -

TOTAL : P7x

TOTAL : P8x/1x Observation Anemia P: Exploration of CBD

13 August 2012 S: Continuous fever (+) Nausea (-) Vomit (-) Loss appetite (-) Urine looked like tea feces appeared to be greenish yellow O: HR : 124 x/minute T : 36,5 C R : 30 x/minute

14 August 2012 S: Continuous fever (-) Nausea (-) Vomit (-) Loss appetite (-) Urine normal

Defecation frequency was normal, the Defecation normal O: HR : 124 x/minute T : 36,5 C R : 30 x/minute

Eyes : anemic conjunctiva -/-, icteric Eyes : anemic conjunctiva -/-, icteric sclera -/-, pupil round, isochors 3mm, light sclera -/-, pupil round, isochors 3mm, light reflex +/+ reactive Abdomen : Inspection : asymmetric, the RUQ seems bigger Auscultation : normal bowel sound Percussion : tympanic reflex +/+ reactive Abdomen : Inspection : asymmetric, the RUQ seems bigger Auscultation : normal bowel sound Percussion : tympanic

Palpation : soft, distention (+), mass (+) Palpation : soft, distention (+), mass (+) a/r RUQ, mobile, cystic consistency, pain a/r RUQ, mobile, cystic consistency, pain when palpate Input Oral : 1000 cc i.v : 480 + 10 Blood : when palpate Input Output TOTAL

TOTAL : 1490 Output

Urine : P7x Vomit : Feces : 1x Blood : A: P: Exploration of CBD

TOTAL : P7x/1x A: P: Exploration of CBD