1.  ID : 53 years old female  CC : Abdominal Pain

2. 53 years old female Abdominal 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 ago Gas passage : -

3. Vomiting : + Not bloody Non biliary Contained food remnant No abdominal distention No urinary symptoms No history of fever Hematemesis: - Rectorrhagia: -

4.  Drug history :  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:  Family history: Negative

5.  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

6.  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

7. Hb16.417.515 WBC660060007800 neut88%84.3%87.2% Plt222204142

8.  Na: 140.6 K: 3.71 BS: 189 Urea: 48 Cr:0.93  Amylase: 226.2Ca:8.4P:2.7  PT:15PTT:40INR:1.19  AST:61ALT:94ALP: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

9.  Liver: normal  CBD: 16mm, dilation of intrahepatic biliary ducts  Spleen and kidneys are normal

12.  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

13.  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