jesus martin generoso, jr.. fr, 50 male married roman catholic mandaluyong informant: patient...
DESCRIPTION
5 weeks PTA Nonradiating intermittent epigastric pain, 5-6/10, “kumikirot” No specific timing or setting, no aggravating factors, no other associated symptoms Temporarily and partially relieved by aluminum/magnesium hydroxide (antacid, Kremil-S) No consult done Abdominal pain persistedTRANSCRIPT
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Jesus Martin Generoso, Jr.
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FR, 50 maleMarriedRoman catholicMandaluyong Informant: patient and wife, poor to
fair reliabilityAdmitted February 19, 2011
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5 weeks PTA Nonradiating intermittent epigastric pain,
5-6/10, “kumikirot” No specific timing or setting, no
aggravating factors, no other associated symptoms
Temporarily and partially relieved by aluminum/magnesium hydroxide (antacid, Kremil-S)
No consult done Abdominal pain persisted
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2 weeks PTA Increase in intensity of intermittent
epigastric pain to 9-10/10, radiating to the back, “sinasaksak”
No noted aggravating/relieving factors, no specific timing or setting
Consult was done at the ER, diagnosed with ulcer, given lansoprazole
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1 week PTA Still with the noted more intense
epigastric pain Consult was done at ER, was given
lansoprazole, diagnosed with PUD, sent home
CBC•HGB – 114 (dec)•HCT 0.36 (dec)•WBC 14.0 (inc)
•Segmenters 0.85•Lymphocytes 0.15
•Platelets adequate
Urinalysis •Bacteria – moderate•Epithelial cells - moderate
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6 days PTA Undocumented remittent high-grade fever Developed yellowing of the skin, urine like
aced tea, and ash-colored stools Still with intense abdominal pain or same
previous character 2 days PTA – consulted
Jaundiced, tea-colored urine, icteric sclerae, sallow skin.
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2 days PTA – consulted Jaundiced, tea-colored urine, icteric
sclerae, sallow skin. t/c hepatitis For concurrent lab work up and
ultrasound
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UTS of liver, gall bladder, biliary tree Gallbladder wall not thickened Fatty liver Obstructing choledocolithiasis and
cholecystolithiasis with secondary biliary dilatation
SGPT 77.6 u/l (0-40)SGOT 52.9 u/l (0-40)Anti HAV IgM and IgG – nonreactiveAlk Phos – 204 u/l (35 -130)
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(-) diarrhea, (-) vomiting, (-) constipation, (-) chills, (-) weight loss, (-) cough and colds, (-) easy bruisability, (-) trauma, (-) melena, (-) hematochezia, with occasional ascending retrosternal pain associated with sour/bitter taste in mouth
Diagnostics were followed-up ,hence admission
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(+) HTN highest BP 160/110, unknown usual BP Maintained with Losartan 50 mg OD,
amlodipine 5 mg OD (+) urolithiasis, unrecalled details (-) DM, (-) asthma, (-) TB, (-) CA, (-)
allergies, (-) bleeding disordersNo previous operations
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(+) HTN (-) DM, (-) TB, (-) gall stones,
(-)allergies
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Married, with 4 kids Jeepney driver for 30 yearsDenies alcohol and cigarette consumptionNo hazardous chemical exposureFond of fatty and fried food, consumes 2-3
cups of rice per meal (2-3 meals per day), with some vegetables, not fond of coffee, likes to drink carbonated beverages
No exercise regimen
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Cutaneous – no rashes HEENT – no headache, no dizziness, no blurring
of vision, no tinnitus, no epistaxis, no dysphagia, no throat pain
Cardiac – no orthopnea, no paroxysmal nocturnal dyspnea, no chest pain, no palpitations
Respiratory – no difficulty breathing, no hemoptysis
GU – no hematuria, no dysuria, no frequency, no retention
Extremities – no calf pain, no claudication Neurologic – no one-sided weakness, no loss of
consciousness
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VITAL SIGNS
BP 110/70 HR 94 RR 23 Temp 38.7
GENERAL SURVEY
Seen lying down Awake, alert,
coherent In distress With chills
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SKIN
Slightly sallow No cyanosis Good turgor
HEENT
Icteric sclerae, pale palpebral conjunctiva
(-) CLAD, (-) TPC, trachea is midline
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CARDIAC
Adynamic precordium No heaves or thrills Apex at 5th ICS LMCL Tachycardic
RESPIRATORY
Symmetric chest expansion
Resonant lung fields With slight/occasional
crackles both lung bases
(-) wheezes, (-) rhonchi
(-) decreased breath sounds
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ABDOMEN Globular No caput medusae Hypoactive bowel
sounds Tympanitic LUQ, RUQ,
LLQ; dull RLQ With epigastric direct
tenderness, with RUQ direct tenderness, murphy’s sign assessment questionable
EXTREMITIES
No cyanosis Pulses full and equal
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HISTORY
50 M With epigastric pain
radiating to back Jaundice Fever UTS findings Laboratory findings
Increased alkaline phosphatase
PHYSICAL EXAMINATION
Tachycardic, tachypneic, febrile
Jaundiced With epigastric
tenderness
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Cholecystolithiasis and choledocholithiasis, in probable ascending cholangitis; r/o gallstone pancreatitis
Hypertension stage II, level of control unknown
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Differentials
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RULE IN
Epigastric pain radiating to the back
With UTS of gallstones and stones in the biliary tree
Fever Jaundice Epigastric and RUQ
tenderness
CANNOT TOTALLY RULE OUT No symptoms of
malabsorption
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RULE IN
Abdominal pain Diet of the patient Increased alkaline
phosphatase
RULE OUT
Gall bladder wall not thickened on UTS
Questionable murphy’s sign
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RULE IN
Intermittent epigastric pain
With GERD symptoms Diet of the patient Epigastric tenderness
RULE OUT
Jaundice Abdominal pain with
no specific timing or setting
RUQ tenderness
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Operation done: emergency open cholecystectomy IOC, and common bile duct exploration and T-tube insertion