ID : 53 years old female

CC : Abdominal Pain

PRESENT ILLNESS:53 years old femaleAbdominal pain since three days ago generalized Constant Without radiation Not related to the patient’s position No relation to meals Anorexia: +Last defecation: 2 days agoGas passage : -

PRESENT ILLNESS:Vomiting : + Not bloody Non biliary Contained food remnantNo abdominal distentionNo urinary symptomsNo history of feverHematemesis: -Rectorrhagia: -

Drug history : Negative

Past medical history: History of cholecystectomy 20 years ago History of laparatomy due to

bowel obstruction 10 years ago History of similar symptoms 3

years ago without operation

Family history: Negative

PHYSICAL EXAMINATION:

Old female, lying on the bed, ill but not toxic

BP: 100/75 PR: 110 T: 37.2 RR: 16

Conjunctiva was not pale, sclera was not icteric, JVP was not elevated

S4 was auscultated in heart examination lungs were normal

PHYSICAL EXAMINATION: Abdominal examination :

Fatty abdomen with midline laparatomic scar and drain scar in RUQ

Bowel sounds were hypoactive Generalized tenderness No guarding, no rebound tenderness

TR: Not bloody, No tenderness, Empty ampula

LAB DATA:Hb 16.4 17.5 15WBC 6600 6000 7800neut 88% 84.3% 87.2%Plt 222 204 142

LAB DATA: Na: 140.6 K: 3.71 BS: 189 Urea: 48

Cr:0.93 Amylase: 226.2 Ca:8.4 P:2.7 PT:15 PTT:40 INR:1.19 AST:61 ALT:94 ALP:134 U/A: PH: 6 color: yellow Appearance:

Clear WBC: 2-3 RBC: 2-3 EP: 1-2 ABG: PH:7.40 PCO2:27 HCO3:17.5

Sonography: Liver: normal CBD: 16mm, dilation of intrahepatic

biliary ducts Spleen and kidneys are normal

Lab data after 1st surgery WBC: 8200 HB:17.5 PLT: 75200 PTT: 36 PT: 19 INR: 1.6 U/A: prt: 1+

blood: 3+

AST: 44.9 ALT: 22 ALP: 113 ALB: 2.1 Amylase: 161 NA: 141 K: 5.4 Ca: 8 P: 4.3 BS: 74 Cr: 1.1 Urea: 54 CPK: 274 CPK-MB: 49

Lab data after 2nd surgery WBC: 5400 HB:8.3 PLT: 30200 PTT: 40 PT: 20 INR: 2

NA: 157 K: 3.8 Ca: 7.6 P: 3.2 BS: 123 Cr: 1.6 Urea: 63.2