GS III Preceptorials January 28, 2012 Block 10a. General Data 55 y.o. Male Farmer Roman Catholic...
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Transcript of GS III Preceptorials January 28, 2012 Block 10a. General Data 55 y.o. Male Farmer Roman Catholic...
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