Case report

Saturday 14-feb-2004
dr_3o3o@hotmail.com
23-12-1424
File# 0000000
Room 000-E

By:

Patient ID:
Name: whatever forever
Age: 55 y/o
Gender: female.
Nationality: Saudi.
Occupation: house wife.
Mode and source of admission:
Emergency admission from ER department 14 days ago
Chief complaints & duration:
Abdominal pain, 2 days duration before admission.
Hx of present illness:
Pt was apparently well till 2 weeks ago, when she started feeling a sudden pain in Rt
hypochondrium of abdomen radiating to Lt hypochondrium Pt couldnt describe the
nature of the pain. It was sever pain and steady in its course. Pain was relieved on some
medicine from ER department 2 days before admission then come back and decreases
after admission. She vomits once after a meal. The vomit was recognizable food. Also she
had abdominal distension. No aggravating factors. She never has like this pain before.
The Pt said she think the cause is the gallbladder.
Past Hx:
- Medical: No Hx of medical disease.
- Surgical: No Hx of surgical procedure.
- Trauma: No Hx of trauma
- Blood transfusion: No Hx of blood transfusion.
- Gynecological: No gynecological Hx
- Allergy: No known allergy.
Drug Hx
No remarkable drug Hx
No allergy to any drug.
Family Hx:
No remarkable family Hx
Parents: no remarkable Hx
Siblings: no remarkable Hx
Childs: no remarkable Hx

Traveling Hx:
She never has been out Saudi Arabia.
Social Hx:
No smoking, no drinking.
Systems review:
Alimentary:
- Vomiting: as described
- Abdominal distension:
- Decreased appetite (anorexia) because she of the pain.
- Unchanged weight.
- No heart burn
- No hematemesis.
- No regurgitation.
- No dysphagia.
- Normal taste and teeth.
- No indigestion.
- No flatulence.
- Normal defecation and bowl habits.
- No skin changes.
Respiratory system:
- No cough.
- No sputum.
- No hemoptysis.
- No dyspnea.
- No chest pain.
Cardiovascular
Cardiac symptoms
- No breathlessness
- No orthopnea, no paroxysmal nocturnal dyspnea.
- No chest pain.
- No cough and sputum.
- No palpitation.
- No hypertension.
- No dizziness (NO headache)
- No ankle swelling.
Peripheral vascular symptoms
- No pain in muscle on exercise.
- No pain at rest in limb.
- No cold extremities.

- No change in color of extremities.

- No tingling or numbness.
Musculoskeletal
- No pain in muscle neither joints.
- No swelling
- No limitation of movement.
- No congenital abnormalities.
Urogential:
Urinary tract symptoms
- No pain in groin.
- No facial edema.
- Normal micturition.
- Normal urine.
- No polyuria
- No oliguria
- No hematuria
- Normal amounts of water drinking.
- No headache.
- No drowsiness
- Visiual disturbances
- Vomiting
Genital tract symptoms
No discharge from urethra.
6 pregnancies all are normal labors.
No complication of pregnancy
She had 4 children now.
- Urethra
- Menstruation
- Pregnancies
- dyspareunia
- breast
Eye
She went to ophthalmologist few months ago.
- Vision.
- Glasses
- Contact lenses.
- Pain
- Redness
- Excessive tearing
- Double vision
- Blurred vision

- Spot
- Speck
- Flashing light
- Glaucoma
- Cataract
ENT
No vertigo, no tinnitus, no pain in ear.
No epistaxis.
No throat problem.
ear
- Hearing
- Tinnitus
- Vertigo
- Earaches
- Infection
- Discharge
Nose
- Frequent cold
- Nasal stuffiness
- Discharge
- Itching
- Nosebleed
Throat
- Condition of teeth
- Denture
- Gum
- Bleeding gum
- Dry mouth
- Frequent sore throat
- hoarsness
Skin
- No color changes
- No itching.
- Rashes
- Lumps
- Dryness
- Hair
- Nails
Endocrine and metabolic:
No DM, no goiter.
- Thyroid trouble

- Heat or cold intolerance

- Excessive sweating
- Excessive hunger or thirst

Nervous system
- No change in mental status.
- Any change in behavior.
- Depression.
- Normal sensation
- No paraesthesia
- Does Pt ever become unconscious?
- Any weakness or paralysis in face or limbs?
- Tremor or involuntary movement.

Lymphatic systems
- No edema.
- No Hx of swellings.
Problem list (1)
Active:
Abdominal pain.
Decreased appetite.
Inactive:
Vomiting
Abdominal distension.
Vision problem
Physical examination
Date: 14-feb-2004
Generally:
Pt was sitting comfortable but sad face, well built body, not pale, not cyanosed.
Head and neck:
On inspection:
Eye: yellowish coloration of sclera.
Conjunctiva: not pale.
Tongue:
- No atrophy
- No dehydration.
- No Lingua nigra
- No Geographical tongue
- No Lrukoplakia

- No Glossitis
- Macroglossia
Teeth:
- Gum hypertrophy.
- False teeth
On palpation:
Submental L.N.
Submandibular L.N.
Preauricular L.N.
Postauricular L.N.
Occipital L.N.
Deep cervical L.N.
Superficial cervical L.N.
Supra clavicular L.N.
Infra clavicular L.N.
Trachea is in normal position.
Supra sternal notch is normal.

Not palpable.
Not palpable.
Not palpable.
Not palpable.
Not palpable.
Not palpable.
Not palpable.
Not palpable.
Not palpable.

Hand:
Normal temp.
No clubbing
no splinter Hemorrhage
no colonechia.
No palmar erythema
no atrophy.
Normal Color of nail bed.
No Muehrcke lines, Mees line, Psoriatic nail, Plimmer nail (onycholysis), Ulnar
deviation,
oslers
nodes,
Janeway
lesion,
Tendon
xanthoma,Palmar
xanthoma,Dupuyterns contracture,Tremor or asterixis, Pupura.
Abdomen:
On inspection:
Abdomen looks symmetric, flat.
Normal skin color, hair distribution and costal angle.
Normal respiratory movement.
Umbilicus normal in site and shape.
No scars, no swelling, no ulcer, no visible peristaltic movement.
On palpation:
Normal temperature.
No tenderness.
No swelling.

Auscultation:
Normal bowl sounds.

Lower extremities:
On inspection:
No swelling (edema)
Normal color.
No deformities.
On palpation:
Normal temperature.

Problem list (2)

Active:
jaundice

Clinical impression:
? Gall stone with jaundice.
? Acute cholicystitis.
Differential diagnosis:
? Cholangitis.
? Acute hepatitis
? perforated peptic ulcer
? high retrocecal appendicitis
? acute pancreatitis
? Rt side basal pneumonia
List investigation:
LFT (liver function test)
CBC (Complete blood count)
Plain radiography of biliary system.
Ultrasonography of biliary system.
ERCP (endoscopic retrograde cholangio-pancreato-graphy)