CHRONIC CHOLECYSTITIS

November 10, 2021

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

[ ] CHIEF COMPLAINTS
A 30year old female patient came to causality with cheif complaints of
Pain abdomen since 3months

[ ] HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 3 moths back, then she developed mild dull aching pain in the epigastrium and right hypochondrium
Which was sudden in onset , continuous,gradually progressive in nature.
Then she consulted an rmp and took medication for one month.
One month back since the pain is not subsiding so got herself checked in the private hospital and then she was diagnosed as chronic cholecystitis secondary to acute pancreatitis.(through usg)
(Pantoprazole ,Tramadol)
6 days back she presented to the general surgery opd with complaints of pain and was referred to general medicine department on 6th november 2021.
There is no history of vomiting ,fever,constipation ,burning micturition.

[ ] PAST HISTORY.
No history of similar complaints in the past
not a known case of Diabetes,Hypertension,Epilepsy,Tb,Asthma.
She is a known case of PCOD 2 years back
She has undergone tubectomy 4 years back after the birth of 2nd child .

[ ] FAMILY HISTORY
Not significant

[ ] PERSONAL HISTORY
Diet :mixed
Appetite:decreased due to pain.
Bowel and bladder:Regular
Sleep :inadequate due to pain.
Addictions:no addictions.

[ ] MENSTRUAL AND OBSTETRICS HISTORY
Age of menarche 16 years
7/28 cycle
Lmp :oct 15.
P2 L2
Known case of pcod since 2 years
Tubectomy 4 years back .

[ ] GENERAL EXAMINATION
The patient is conscious coherent cooperative
Moderately built and moderately nourished
Well oriented to time place and person .
No pallor
No icterus
No cyanosis
No clubbing
No lymphadenopathy
No edema

VITALS
Temp :afebrile
BP 110/70mmHg
RR 18cpm
HR 76bpm

[ ] SYSTEMIC EXAMINATION

RS :BAE+ NVBS+
CVS: S1S2+, No murmurs
CNS: no focal neurological deficits
PA :
INSPECTION:
1.      Shape – normal

2.      Flanks – free

3.      Umbilicus –
Position: central,
Shape-inverted

4.      Skin – normal

5.   Movements of the abdominal wall: normal

6.     Hernial Orifices: absent

PALPATION:
Superficial Palpation –
Tenderness: non tender
Warmth: no rise of temperature

Deep Palpation

1.      Liver:

non tender and no rise of temperature
No hepatomegaly

2.      Spleen

non-tender , no rise of temperature

3.      Kidney

non-tender , no rise of temperature

Measurements -
Abdominal Girth:
Spino-Umbilical Distance
Distance between the xiphisternum-Umbilicus:

Distance between Umbilicus-Pubic Symphysis:

Hernial Orifices: absent

Murphy’s Punch/Renal angle tenderness:

PERCUSSION:
1.      Fluid Thrill/Shifting dullness/Puddle’s sign: absent
2.      Percussion of Liver for Liver Span: normal

3.      Percussion of Spleen for Splenomegaly – Nixons method, Castell’s method, Barkun’s method of percussion of the Traube’s space : normal

AUSCULTATION:

1.      Bowel sounds – 10 to 15/min for small bowel, 3 to 5/min for large bowel : heard

2.      Bruit – Aortic, Hepatic, Renal Bruit: absent

INVESTIGATIONS:

CT SCAN -ABDOMEN AND PELVIS