GS III PreceptorialsJanuary 28, 2012

Block 10a

General Data55 y.o. MaleFarmerRoman CatholicLubang Island, Occidental Mindoro

Chief Complaint: RUQ abdominal pain

History of Present Illness

History of Present IllnessRecurrence of:•RUQ abdominal pain, same

character as the initial symptoms, (-) vomitiing, fever, jaundice (+) good bowel movement

•Consulted PGH OPD advised surgery.

•In the interrim,still with persistence of symptoms, patient went home to generate funds for the surgery.

3 months PTA

Review of Systems(-) unexplained weight loss, weakness, fever,

fatigue(-) HA, BOV, cough, colds(-) chest pain, palpitations, DOB, orthopnea(-) jaundice, anorexia, easy satiety, vomitting(-) LOM, joint pain

Past Medical History(-)allergies, asthma, diabetes, hypertension,

Family Medical History(-) similar condition in the family(+) HPN – father(-) CA, allergies, asthma, DM, TB

Personal/Social History38 pack years smoker, occasional alcoholic

beverage drinker, denies drug useHS grad, farmerFond of fatty and salty foods, diet consists

mainly of fish, meat, and rice.

General Survey

alert, coherent, ambulatory, not in cardiorespiratory distress

Vital Signs BP 120/80 HR 76 RR 20 Temp 36.7

HEENT: anicteric sclerae, pink conjunctivae, (-) CLAD, (-) NVE, (-) neck mass

Chest/Lungs:

equal chest expansion, clear breath sounds, (-) crackles/wheezes

CVS: adynamic precordium, distinct S1 and S2, normal rate, regular rhythm, (-) murmurs, (-) heaves/thrills

Physical Examination

Abdomen •flat, undisteded abdomen, with no visible mass, or gross abnormalities•Normoactive bowel sounds•liver not enlarged (liver span 8cm), intact traube’s space, no spleenomegaly•Upon light palpation, no mass/tenderness on all quadrants•Upon deep palpation, no masses palapated on all quadrants, (+) tenderness RUQ•(+) murphy’s sign, (-) rovsing’s/psoas/obturator sign

DRE good sphincter tone, smooth rectal mucosa, intact rectal vault (-) masses (-) tenderness (-)blood per examining finger

Skin/Extremities

full and equal pulses, pink nail beds, good CRT, (-) clubbing, cyanosis, edema

Physical Examination

Assessment

Cholelithiasis

LaboratoryCBC

Hgb 158

Hct 0.490

WBC 6.8

Plt 296

Monocytes 0.07

Eosinophils 0.03

Basophils 0.00

Neutrophils 0.56

Lymphocytes 0.34

LaboratoryGlucose 5.40 mmol/LBUN 4.50 mmol/LCreatinine 83.6 umol/LNa 139K 3.9Cl 105

LaboratoryUrinalysis

Yellow/hazy/sp gr 1.030/pH 6.0/(-) sugar/albumin/casts/crystals

WBC 0-2/hpf, RBC 0-1/hpfCXR

No significant chest findings

DiagnosticsHBT Ultrasound

The liver is not enlarged It has smooth bordersThere is no parenchymal echogenicityNo focal mass lesions are seen

DiagnosticsThe intrahepatic ducts and common bile duct

(3.7mm) are not dilated. The portal vein (0.9cm), inf vena cava and the hepatic veins are unremarkable

The gallbladder is normally distended with unthickened walls. Multiple high intensity echoes wit posterior sonic shadowing are seen within the gallbladder with an aggregrate diameter of 1.3cm.

Impression:Normal utz of the livercholelithiasis