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1. HX - HOPI (SOCRATES)

site- right upper quadrant, specific loc- hypochondriac, lumbar,periumbilical,epigastric

onset-sudden or gradual, how many times did the pain occured

characteristics- sharp, burning, colicky, dull, cramping

radiation- radiate to the back

assc symptoms- relieving factors- rest, med, position, food

time- how long, duration, reccurent episodes

exacerbating factors- relieving factors- rest, med, position, food

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-no difficult terms

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1. 46 yo woman - middle aged, mild immune system response, reproductive age

2. ruq abdominal pain - ex : hepatitis, congested hepatomegaly, right lobe pneumonia

organs - liver, gallbladder, duodenum, head of pancreas, right kidney

3. er - need immediate treatment, acute pain,

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1. resp system

pneumonia - pleuritic chest pain, sharp pain (SOB, chest pain, contact w another person w the same symptoms)

pneumothorax- pleuritic chest pain, sharp pain (blunt trauma)

2. GIT

AAA- central abdominal pain, if pain radiated- radiation of the pain from central (any central radiate to back pain, hypertension, DM)

cholelithiasis - acute (COLICKY PAIN, aggravted by spicy fatty meals)

cholecystitis (same as above)

cholangitis (jaundice)

cholangiocarcinoma (jaundice, loss of weight, loss of appetite)

acute pancreatitis (pain radiate to back, fever)

gastritis (central pain of epigastric region, food intake, nausea, vomiting, spicy food intake)

peptic ulcer (same as above)

gastroenteritis (diarrhea, vomiting, food intake)

appendicitis - atypical loc of appendix (umbilical pain, RIF pain)

hepatitis (A- jaundice, fever, diarrhea hepatomegally, B&C - jaundice)

liver abscess (fever, jaundice)

3. GU

right kidney stone (colicky, ask for UTI symptoms, hematuria)

pylonephritis (infection, UTI symptoms, fever)

4.reproductive

ovarian torsion (towards lower part)

ectopic pregnancy (miss period)

5. CVS

MI ( in dextrocardia) (chest pain, sharp pain, SOB, sweating, pain radiated to jaw and right arm)

aortic dissection (pain radiate to mid scapula region)

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1. Gestational diabetes - type of diabetes develop during pregnancy, second and third trimester, resolved after pregnancies

2. intermittent dull pain -steady or persistent pain that is low to moderate in intensity, can indicate gall bladder issue

3. diaphoresis - excessive sweating

4. oral contraceptive -m hormonal med to prevent pregnancies, stop ovulation period

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1. the pain started about 12 hours earlier in the upper abdomen after a fatty

meal that had become progressively more severe - acute pain, very severe

2. pain is

continuous, radiates into the back and scapula

3. nauseated,

alternatively hot and cold

4. having intermittent dull pain over the previous

year in the right upper abdomen that occurred after large meals

which resolved spontaneously within an hour and mentions that

taking antacids did not help with her recurrent pain - before, resolve spontaneously but now getting worse. a recurrent episode

5. denies chest pain, heartburn, lower abdominal pain, diaphoresis, and

dizziness. stool

was normal in colour and consistency

6. very obese before - she try to avoid fatty food now

7. Gestational diabetes - risk factor of having DM

8. takes combined oral contraceptives - weight changes, risk factor of OCP, 4F, increase risk of gall bladder disease, estrogen level effect

9. not smoker and does not drink alcohol - rule out carcinoma

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PE

Inspection

1. Physical appearance- jaundice, pallor, oriented, BMI

2. vital sign - BP (high as he's in pain), HR (increase), RR (normal), Temp (normal or slightly high), pain score

3. Abdominal examination - surgical scars, abnormal asymmetrical of the abdomen, palpate for any mass such as hepatomegaly, palpate at the site of pain to check for tenderness, look for guarding, Murphy's sign

4. Auscultate - for bowel sounds

5. Percussion - if there any mass, fluid

Investigation

LAB TEST

1. Ultrasound

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1. resp system

pneumonia - pleuritic chest pain, sharp pain (SOB, chest pain, contact w another person w the same symptoms)

pneumothorax- pleuritic chest pain, sharp pain (blunt trauma)

2. GIT

AAA- central abdominal pain, if pain radiated- radiation of the pain from central (any central radiate to back pain, hypertension, DM)

cholelithiasis - acute (COLICKY PAIN, aggravted by spicy fatty meals)

cholecystitis (same as above)

cholangitis (jaundice)

cholangiocarcinoma (jaundice, loss of weight, loss of appetite)

acute pancreatitis (pain radiate to back, fever)

gastritis (central pain of epigastric region, food intake, nausea, vomiting, spicy food intake)

peptic ulcer (same as above)

gastroenteritis (diarrhea, vomiting, food intake)

appendicitis - atypical loc of appendix (umbilical pain, RIF pain)

hepatitis (A- jaundice, fever, diarrhea hepatomegally, B&C - jaundice)

liver abscess (fever, jaundice)

3. GU

right kidney stone (colicky, ask for UTI symptoms, hematuria)

pylonephritis (infection, UTI symptoms, fever)

4.reproductive

ovarian torsion (towards lower part)

ectopic pregnancy (miss period)

5. CVS

MI ( in dextrocardia) (chest pain, sharp pain, SOB, sweating, pain radiated to jaw and right arm)

aortic dissection (pain radiate to mid scapula region)

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murphy's sign - to asses acute cholecystitis

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1. Obese class 2 BMI: 37.2

2. temp: high - fever

3. heart rate: normal

4. RR: normal

5. BP: normal

6. murphy's sign positive: present of acute cholecystitis - key for gallbladder inflammation

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investigation:

1. FBC - infection (WBC, platelet), hb (preparation for surgery),

2. ABO blood group (management for surgery)

3. CRP/ESR - infection

4. blood culture & sensitivity

5. amylase/lipase : pancreatitis

6. random blood sugar: bcs she has diabetes - risk factor

radiological investigation:

1. ultrasound of abdomen - look for any gallstones

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1. wbc - high (bacteria infection)

2. crp - high (bacteria)

3. esr - high (inflammation / infection)

4. renal function test - preparation for surgery, look for dehydration / not

5. liver function test - indicate jaundice, affect at biliary tract or not, high : obstruction at biliary tract if high bilirubin proceed to ercp

6. 1.7-cm gallstone impacted in the neck of the gallbladder, with a

distended gall bladder and thickening (6.8 mm) of the gall

bladder wall - big enough

7. acute calculous cholecystitis - gallbladder stone

8. hospitalised and started antibiotics (a cephalosporin, e.g. cefuroxime) - normal gi organism (e. coli, klebsiella, enterococcus, anaerobes organism), analgesics, nil by mouth and IV fluids to stabilise her condition

9. performed laparoscopic cholecystectomy on the day 2 and was discharged in stable condition

10. recommended to maintain a healthy weight, combine a balanced high calcium high fibre diet with daily exercise

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ACUTE CALCULOUS CHOLECYSTITIS