Cholelithiasis

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  • Topic: Abdominal pain, Cholecystectomy, Liver
  • Pages : 4 (668 words )
  • Download(s) : 736
  • Published : February 28, 2012
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GENERAL DATA

L.B, 59/F right handed, Catholic, presently residing at Famy Laguna. Admitted for the 1st time at QMMC last January 17, 2012.

CHIEF COMPLAINT: Abdominal pain radiating to the back

HISTORY OF PRESENT ILLNESS:

The patient was apparently well until 4 days PTA, the patient experience abdominal pain located in the epigastric area described as stabbing pain after tasting oily viand that she cooked. She did not took any medication or seek any consult.

2 days prior to admission, she still had intermittent abdominal pain. She also noted that her stool was pale grey in color. She self medicate with Buscopan which gave her a temporary relief.

On the day of consult, the patient experience a more intense continuous epigastric pain with a 8/10 on pain scale radiating to the R upper quadrant then at the back. She felt chilly and had cold clammy skin. She was rush to Pakil Memorial hospital in Laguna. Laboratory tests were done and showed presence of stone obstructing the neck of the bladder on ultrasound.

She was reffered to QMMC for surgery.

PAST MEDICAL HISTORY:

No previous illnesses, hospitalization, blood transfusion were noted. She claimed to have rheumatism (undiagnosed).

OB HISTORY

She is a G14P14(12002) all via NSVD at home assistted by a midwife. The 13th child died due to abruptio placenta and curretage was done. She had her menopause at 55 years old.

FAMILY HISTORY:

Father has rheumatism

Mother has a tumor in the uterus

The patient has no heredofamilial disease like diabetes, asthma, hypertension.

PERSONAL & SOCIAL HISTORY:

The patient is married with 12 children. Works as a market vendor. She is fond of eating salty and fatty foods. She is a non smoker, occasional alcoholic drinker, denied any illicit drug used.

REVIEW OF SYSTEMS:

(-) headache(-) chest pain(+) weight lost

(-) fever(-) diarrhea (-) nausea and vomiting

(-) rash & pruritus(-) constipation (-)...
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