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General data C.D 43 y.o. Female Married Roman Catholic August 4, 1966 Solana,Cagayan July 29, 2010

Chief complaint Right upper quadrant pain

History of Present Illness 1 year PTA - recurrent RUQ colicky pain UTZ cholecystolithiasis 3 months PTA - consulted a PMD and Omeprazole was prescribed Still with RUQ pain - admission

Past Medical History August 2009 surgery due to a laryngeal cyst at SPH

Family History unremarkable

Personal and Social History Non-cigarette smoker Non-alcoholic beverage drinker

Review of Systems Integumentary: (-) pruritus CNS: (-) seizure, (-) h/a, (-) dizziness Cardiorespiratory: (-) cough, (-) chest pain GIT: (-) vomiting, (-) diarrhea, (-) constipation GUT: (-) oliguria, (-) hematuria, (-) dysuria

Hematologic: (-) gum bleeding, (-) easy bruisability Muskuloskeletal: (-) myalgia, (-) arthralgia Endocrine: (-) weight loss, (-) loss of appetite,(-) fever

Physical Examination: General Survey: Px is conscious, coherent and not in cardiorespiratory distress

Vital Signs: BP: 120/90 CR: 98 bpm RR: 20 bpm Temp: 36.8 C

Skin: (-) pallor, good skin turgor HEENT: pink palpebral conjunctiva Chest and Lungs: (-) rales, (-) wheezes Heart: AP, NRRR, (-) murmur Abdomen: flabby, (+) Murphy s sign Extremities: (-) edema, FEP

Impression Acute Cholecystitis

Date 7/29/10 11:45 am

Diagnostics CBC, UA, UTZ, Na, K, creatinine, RBS, CXR, 12L ECG Sodium : 149 mmol/L (138-145) Potassium: 4.06 mmol/L (3.5-5.4) Glucose : 5.36 mmol/L (4.10 5.90) Creatinine: 60 umol/L (53 115) Chloride: 104 mmol/L (96 110) ALT: 15 u/L (9 72) ALKP: 82 u/L (38 126)

IVF/Meds Admit to surgery ward Secure consent for admission and management NPO IVF D5LRS 1L q 8 hrs Medicines: AmpiSulbactam 1.5 mg q 12 hrs ANST Ranitidine 50 mg IV q 12 hrs Ketorolac 30 mg IV q 8 hrs For E cholecystectomy Refer to Medicine for eval n prior to cholecystectomy


Diagnostics CBC: Hgb: 109 g/L (120-160) Hct: 0.33 (0.38 0.47) Erythrocyte no. conc.: 4.9 (4.5 to 6.0 x 109/L) Thrombocyte no. conc.: 243 (150-400 x 109/L) WBC Diff. Ct.: Neutrophils 38.4 (35-65) Lymphocytes 41.3 (2040) Monocytes 19.3 (2-8) Eosinophils 0 (0-5) Basophils 1 (0-1) U/A: Yellow, sl. Turbid pH 6.0 SG 1.030 (-) chemical test WBC 12-15/hpf, RBC 6-9 Bacteria - few

IVF/ Meds


Diagnostics UTZ of of Hepatobiliary tree and Pancreas Result: Cholelithiasis CXR: no cardiomegaly, no infiltration 12L ECG : sinus rhythm, non-specific ST-T wave changes

IVF/ Meds

7/29/10 3:45 pm BP: 130/90, HR: 81 bpm, RR: 18 bpm

Patient seen and examined Patient was referred for eval n due to cholecystectomy A: stable cardiopulmonary status at the time of examination P: no absolute CI for the contemplated procedure

Date 7/30/10 1:00 am


IVF/ Meds Post op orders Status post cholecystectomy NPO Monitor VS q 15 mins. Until stable OR @ 5-6 pm via face mask IVF: Plain NSS x 30 gtts/ min , D5LRS x 30 gtts/min Meds: Intrathecal morphine given Ketorolac 30 mg IV q g hrs after negative skin test Tramadol 50 mg IV PRN moderate to severe pain Ranitidine 50 mg IV q 8 hrs while on NPO

Date 7/30/10 8:50 am


IVF/ Meds Soft diet IVF: D5LRS 1L q 8 hrs Continue meds Probable discharge tomorrow D/C Tramadol MGH Dulcolax 2 adult suppository now Bladder draining prior to discharge Home Meds: Cefuroxime 500 mg TID for 7 days Ketomed 10 mg 1 tab TID Omeprazole 20 mg BID Follow-up - Aug. 5, 2010 Discharge


(+) BM Soft, non tender


Prevalence and Incidence one of the most common problems affecting the digestive tract

Factors : -age - gender - ethnic background

Predisposing conditions:- Obesity - pregnancy - dietary factors - Crohn's disease - terminal ileal resection - gastric surgery - hereditary spherocytosis - sickle cell disease - thalassemia

Prevalence and Incidence 3x more in women than men first-degree relatives - twofold greater prevalence

NATURAL HISTORY asymptomatic throughout life Some progress to a symptomatic stage, with biliary colic caused by a stone obstructing the cystic duct - may progress to complications related to the gallstones.

Approximately 3% of asymptomatic individuals become symptomatic per year. Complicated gallstone disease develops in 3 to 5% of symptomatic patients per year.

Gallstone Formation result of solids settling out of solution major organic solutes in bile are: *bilirubin *bile salts * phospholipids *cholesterol

classified by their cholesterol content as either: * cholesterol stones * pigment stones black or brown

CHOLESTEROL STONES single large stones with smooth surfaces contain variable amounts of bile pigments and calcium, but are always >70% cholesterol by weight

Most cholesterol stones are radiolucent Whether pure or of mixed nature: common primary event in the formation of cholesterol stones is supersaturation of bile with cholesterol.