# data[].attributes.body
1. Normal Hb, sodium, potassium, urea, bilirubin, cratinine, GGT, platelet
2. High white cell count- neutrophil predominant
3. High ESR and CRP
4. Abdominal US show 1.7 cm gallstones impacted in neck of gallbladder with a distended gall bladder and thickening gallbladder wall
5. Diagnosed with acute calculous cholecystitis

the rest may be discuss in LO
- eleborate the investigation
- why high ESR and CRP
- no need management
- advice for patient that has no gallbladder

# data[].attributes.body
1. laparoscopy cholecystectomy- minimally invasive surgical procedure to remove disease of gallbladder
2. cephalosporin- beta-lactam antimocrobial use to treat infection.

# data[].attributes.body
Differential diagnosis
1.  cholecystitis
2. pancreatitis
3. cholangitis - jaundice, HT
4. gallstone (cause for cholecystitis)
5. liver abscess (complication of cholecystitis)

Further questioning
1. FBC, CRP, ESR, TWBC, differential WBC
2. Imaging test - ultrasound, CT scan -> check for gallstone & to rule out liver abscess
3. Liver Function Test

# data[].attributes.body
1. pt appear uncomfortable and feels better when lie in bed and not move
- LO

2. weight 105kg, height 168cm
- excessive visceral fat surrounding organ that might affect its function - form cholesterol stone and predispose to high bile secretion & accumulation in gallbladder

3. high temperature (fever)
- indicate inflammation

4. normal HR, RR, BP
- indicate normal cardio and respiratory system

5. soft abdomen but tender in RUQ
- no peritonitis
- indicate inflammation

6. no rebound tenderness
- no peritoneal irritation, less likely peritonitis

7. murphy's sign was positive and bowel sounds normal
- suggest acute cholecystitis

8. rest of examination unremarkable
- other system are normal

# data[].attributes.body
1. murphy's sign - ask pt to take in and hold deep breath while palpating rt. subcostal area. positive if feels pain - acute cholecystitis
2. rebound tenderness - there is pain when pressure is released

# data[].attributes.body
Differential diagnosis
1.  cholecystitis
2. pancreatitis
3. cholangitis
4. gallstone
5. liver abscess

further questioning
1. vital signs- BP,T,RR,HR

2. Physical examination
- inspection ( jaundice, scar, abdominal distension, General appearance, charcott triad suspect cholangitis)
- palpation ( tenderness, masses, rebound tenderness, Murphy's sign)
- percussion (dullness for liver, gallbladder,kidney)
- auscultation ( check bowel sound)

3. BMI
-Weight, height

# data[].attributes.body
1.pain started 12h earlier after fatty meal that had become progressively more severe
- could be cholecystitis, gallstone,choledocholithiasis
-due to excrete more bile and gallbladder to contract
- 12h- acute

2. pain is continous, radiate to the back and scapula
-reffered pain

3. feels nauseated , alternatively hot and cold
- feedback mechnism of nausea and vomiting
-hot-fever mechnism
- due to inflammation response (hot and cold)

4. have intermittent dull pain over hte previous year in the right upper abdomen that occured after large meals which resolved spontaneously within an hour
- sign and symptoms of biliary cholic
- pt feel painful after eat fatty meals

5. taking antacids did not help with her pain
- indicate pt condition less suggestively of gerd, dyspepsia, hyperchlorhydria
- protect GI lining

6. denies chest pain, heartburn, lower abdominal pain, diaphoresis, and dizziness
- (chest pain,heartburn) - eliminate possible MI/ acid reflux
- lower abdominal pain - less likely lower GI
- lower abdominal pain can be pregnancy
- diapheresis can caused by menopause,ask about menstrual history
- diapheresis - premenopausal symptom
- dizziness - may has pregnancy

7. did not notice any changes in bowel habit
- bowel function normal
- not having diarrhea ( No food poisoning, infection)
- constipation ( IBD, less water intake, healthy diet)

8. stool normal in colour and consistency
- no lower GI bleeding

9. very obese in the past
- risk factor to excess cholesterol
-insulin resistance

10. gestational diabetes with previous two pregnancies
-long term complication : type 2 diabetes

11. family history is unremarkable
- Less likely malignancy or inherited disease

12. takes combined oral contraceptive
- increase risk of gallbladder disease if used for long time

13. no history of allergies to food or medicines
- current symptom not due to allergies

14. not smoker and does not drink alcohol
- pain not induced by smoking or alcohol

# data[].attributes.body
1.dull pain- chronic or persistent pain with mild discomfort
2.diaphoresis- excessive sweating
3. gestational diabetes- high blood sugar that develop during pregnancy
4. antacid- an agent/medicine that counteracts the acidity of gastric juice

# data[].attributes.body
Further questioning
1. S = right upper quadrant
O = sudden/gradual
C = Pain (stabbing, burning, dull, gripping, colicky, continuous of intermitten)
R = does it radiate to other part?
A = vomiting, nausea, discolouration of skin/eye, diahrrea, pain in urination, chest pain, fever, heart burn, difficulty in breathing, anorexia (loss of appetite), loss of weight, changes in bowel habit, constipation, hematemesis, malaena, fatty food intolerance.
T = how long experiencing the pain?
E = took any medication to relieve the pain? action that worsen the pain
S = scale 1 to 10 of the pain felt

2. Past medical history: Any chronic disease, trauma in the past,  regular medicaiton,  any allergic to medicaiton

3. Family history: any inherited disease (cancer/malignancy)

4. Social history: smoking, drug abuse, alcohol, lifestyle and diet, occupation

5. Travel history: can cause GE from contaminated food/water

# data[].attributes.body
1. 46 yr old woman - middle age, high possibilities to get metabolic disease, woman more prone to digestive disease (food in the stomach tends to empty into the intenstine more slowly), more oestrogen (can stimulate cholestrol synthesis pathway)
2. Present to emergency department - Patient cannot tolerate the pain, requires special treatment, the patient also require prompt medical attention
3. Right upper quadrant abdominal pain - organ, right lobe of liver, stomach dueodenum, head of pancrease, right suprenal gland, right kidney and also superior part of ascending colon
causes: abdominal pain, trauma, infection, obstruction or side effect of medication