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ID : 53 years old female CC : Abdominal Pain PowerPoint Presentation
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ID : 53 years old female CC : Abdominal Pain - PowerPoint PPT Presentation


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ID : 53 years old female CC : Abdominal Pain. PRESENT ILLNESS:. 53 years old female Abdominal pain since three days ago generalized Constant Without radiation Not related to the patient’s position No relation to meals

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Presentation Transcript
slide1

ID : 53 years old female

  • CC : Abdominal Pain
present illness

PRESENT ILLNESS:

53 years old female

Abdominal pain since three days ago

generalized

Constant

Without radiation

Not related to the patient’s position

No relation to meals

Anorexia: +

Last defecation: 2 days ago

Gas passage : -

present illness1
PRESENT ILLNESS:

Vomiting : +

Not bloody

Non biliary

Contained food remnant

No abdominal distention

No urinary symptoms

No history of fever

Hematemesis: -

Rectorrhagia: -

slide4

Drug history : Negative

  • Past medical history:
    • History of cholecystectomy 20 years ago
    • History of laparatomy due to bowel obstruction 10 years ago
    • History of similar symptoms 3 years ago without operation
  • Family history: Negative
physical examination
PHYSICAL EXAMINATION:
  • Old female, lying on the bed, ill but not toxic

BP: 100/75 PR: 110 T: 37.2 RR: 16

  • Conjunctiva was not pale, sclera was not icteric, JVP was not elevated
  • S4 was auscultated in heart examination
  • lungs were normal
physical examination1
PHYSICAL EXAMINATION:
  • Abdominal examination :
    • Fatty abdomen with midline laparatomic scar and drain scar in RUQ
    • Bowel sounds were hypoactive
    • Generalized tenderness
    • No guarding, no rebound tenderness
  • TR: Not bloody, No tenderness, Empty ampula
lab data1
LAB DATA:
  • Na: 140.6 K: 3.71 BS: 189 Urea: 48 Cr:0.93
  • Amylase: 226.2 Ca:8.4 P:2.7
  • PT:15 PTT:40 INR:1.19
  • AST:61 ALT:94 ALP:134
  • U/A:

PH: 6 color: yellow Appearance: Clear

WBC: 2-3 RBC: 2-3 EP: 1-2

  • ABG:

PH:7.40 PCO2:27 HCO3:17.5

sonography
Sonography:
  • Liver: normal
  • CBD: 16mm, dilation of intrahepaticbiliary ducts
  • Spleen and kidneys are normal
lab data after 1 st surgery
Lab data after 1st surgery
  • WBC: 8200
  • HB:17.5
  • PLT: 75200
  • PTT: 36
  • PT: 19
  • INR: 1.6
  • U/A: prt: 1+ blood: 3+
  • AST: 44.9
  • ALT: 22
  • ALP: 113
  • ALB: 2.1
  • Amylase: 161
  • NA: 141
  • K: 5.4
  • Ca: 8
  • P: 4.3
  • BS: 74
  • Cr: 1.1
  • Urea: 54
  • CPK: 274
  • CPK-MB: 49
lab data after 2 nd surgery
Lab data after 2nd surgery
  • WBC: 5400
  • HB:8.3
  • PLT: 30200
  • PTT: 40
  • PT: 20
  • INR: 2
  • NA: 157
  • K: 3.8
  • Ca: 7.6
  • P: 3.2
  • BS: 123
  • Cr: 1.6
  • Urea: 63.2