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. 1 year and 3 months PTA (+) intermittent abdominal pain ( VAS 8/10, crampy), at the right upper quadrant w/ radiation to the right lower back (-) scapular radiation. Associated with food intake with episodes lasting 20-30 minutes (-) vomitting, jaundice, weight loss, fever, easy satiety (+) good bowel movement Consult at a local private hospital, UTZ done → cholelithiasis → advised surgery, deferred Consulted PGH OPD for 2 nd opinion, UTZ showed small choleliths → given unrecalled meds with relief of symptoms for 1 year 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. 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. General Survey alert, coherent, ambulatory, not in cardiorespiratory distress Vital SignsBP 120/80HR 76RR 20Temp 36.7 HEENT:anicteric sclerae, pink conjunctivae, (-) CLAD, (-) NVE, (-) neck mass Chest/Lungs:equal chest expansion, clear breath sounds, (-) crackles/wheezes CVS:adynamic precordium, distinct S1 and S2, normal rate, regular rhythm, (-) murmurs, (-) heaves/thrills Physical Examination

10. Abdomenflat, undisteded abdomen, with no visible mass, or gross abnormalities Normoactive bowel sounds liver not enlarged (liver span 8cm), intact traube’s space, no spleenomegaly Upon light palpation, no mass/tenderness on all quadrants Upon deep palpation, no masses palapated on all quadrants, (+) tenderness RUQ (+) murphy’s sign, (-) rovsing’s/psoas/obturator sign DREgood sphincter tone, smooth rectal mucosa, intact rectal vault (-) masses (-) tenderness (-)blood per examining finger Skin/Extremitiesfull and equal pulses, pink nail beds, good CRT, (-) clubbing, cyanosis, edema Physical Examination

11. Assessment Cholelithiasis

12. Laboratory CBC Hgb158 Hct0.490 WBC 6.8 Plt296 Monocytes0.07 Eosinophils0.03 Basophils0.00 Neutrophils0.56 Lymphocytes0.34

13. Laboratory Glucose5.40 mmol/L BUN4.50 mmol/L Creatinine83.6 umol/L Na 139 K3.9 Cl105

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