1 / 16

GS III Preceptorials

GS III Preceptorials. January 28, 2012 Block 10a. General Data. 55 y.o. Male Farmer Roman Catholic Lubang Island, Occidental Mindoro Chief Complaint: RUQ abdominal pain. History of Present Illness. Recurrence of:

alida
Download Presentation

GS III Preceptorials

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. GS III Preceptorials January 28, 2012 Block 10a

  2. General Data • 55 y.o. • Male • Farmer • Roman Catholic • Lubang Island, Occidental Mindoro Chief Complaint: RUQ abdominal pain

  3. History of Present Illness

  4. Recurrence of: • RUQ abdominal pain, same character as the initial symptoms, (-) vomitiing, fever, jaundice (+) good bowel movement • Consulted PGH OPD advised surgery. • In the interrim,still with persistence of symptoms, patient went home to generate funds for the surgery. History of Present Illness 3 months PTA

  5. Review of Systems • (-) unexplained weight loss, weakness, fever, fatigue • (-) HA, BOV, cough, colds • (-) chest pain, palpitations, DOB, orthopnea • (-) jaundice, anorexia, easy satiety, vomitting • (-) LOM, joint pain

  6. Past Medical History • (-)allergies, asthma, diabetes, hypertension,

  7. Family Medical History • (-) similar condition in the family • (+) HPN – father • (-) CA, allergies, asthma, DM, TB

  8. Personal/Social History • 38 pack years smoker, occasional alcoholic beverage drinker, denies drug use • HS grad, farmer • Fond of fatty and salty foods, diet consists mainly of fish, meat, and rice.

  9. Physical Examination

  10. Physical Examination

  11. Assessment Cholelithiasis

  12. Laboratory CBC • Hgb 158 • Hct 0.490 • WBC 6.8 • Plt 296 • Monocytes 0.07 • Eosinophils0.03 • Basophils 0.00 • Neutrophils 0.56 • Lymphocytes 0.34

  13. Laboratory • Glucose 5.40 mmol/L • BUN 4.50 mmol/L • Creatinine 83.6 umol/L • Na 139 • K 3.9 • Cl 105

  14. Laboratory • Urinalysis • Yellow/hazy/sp gr 1.030/pH 6.0/(-) sugar/albumin/casts/crystals • WBC 0-2/hpf, RBC 0-1/hpf • CXR • No significant chest findings

  15. Diagnostics • HBT Ultrasound • The liver is not enlarged • It has smooth borders • There is no parenchymal echogenicity • No focal mass lesions are seen

  16. Diagnostics • The intrahepatic ducts and common bile duct (3.7mm) are not dilated. The portal vein (0.9cm), inf vena cava and the hepatic veins are unremarkable • The gallbladder is normally distended with unthickened walls. Multiple high intensity echoes wit posterior sonic shadowing are seen within the gallbladder with an aggregrate diameter of 1.3cm. • Impression: • Normal utz of the liver • cholelithiasis

More Related