1. Presented by: GAW, Gem Minnie Mae GO, Stephanie M. GONZALES, Alexander II

2. L.D.L. 50/F Filipino Roman Catholic Married High school graduate Date of admission: February 1, 2012 Informant: patient

3. Abdominal pain

4. 3 months PTA Abdominal pain, RUQ radiating to the back, colicky, associated with bloatedness and not affected by food intake No fever; no nausea, no vomiting, no diarrhea; no jaundice; no acholic stools; no tea-colored urine Consult: WA UTZ: cholecystolithiases Advised: for surgery No medications taken

5. 1 month PTA Increase in intermittence of abdominal pain, RUQ, colicky, aggravated by food intake No fever; no nausea, no vomiting, no diarrhea; no jaundice; no acholic stools; no tea-colored urine Consult: EAMC OPD, scheduled for open cholecystectomy

6. 1 week PTA Abdominal pain, RUQ associated with jaundice, undocumented febrile episodes No nausea, no vomiting, no pruritus, no acholic stools, no tea-colored urine Consult: EAMC OPD admission

7. General: no weight loss/gain Skin: no rashes HEENT: no blurring of vision, no itching, no discharge, no changes in hearing acuity, no tinnitus, no ear pain, no ear discharge, no epistaxis, no nasal discharge, no gum bleeding Respiratory: No cough, no dyspnea, no hemoptysis Cardiovascular: No chest pain, no orthopnea, no easy fatigability Gastrointestinal: HPI Genitourinary: No dysuria, no incontinence Musculoskeletal: No joint pain, no muscle pain, no weakness Neurological: No headache, no seizures Endocrine: No heat and cold intolerance, no palpitations, no tremors Psychiatric: No anxiety, no depression, no hallucinations Hematologic: No easy bruising, no prolonged bleeding

8. (-) Hypertension (-) Diabetes mellitus (-) bronchial asthma (-) Pulmonary TB (-) allergy (-) blood dyscrasia No previous surgeries and blood transfusion

9. (+) Hypertension – mother and father (-) Diabetes mellitus (-) bronchial asthma (-) cancer (-) blood dyscrasia (-) gall bladder disease (-) kidney disease (-) heart disease

10. Non-smoker Non-alcoholic beverage drinker Mixed diet of chicken and meat (prefers fried and salty food), occasional vegetables and fish, drinks 3-4 glasses of water a day

11. Menopause: 47 y/o G2P2 (2002) No complications No miscarriages No abnormal vaginal discharge No history of OCP use

12. Conscious, coherent, oriented to time, place, and person, ambulatory and not in cardiorespiratory distress BP 130/80 mmHg PR 92 bpm,regular RR 21 cpm, regular T: 36.9 °C Height 160.02 cmWeight 64 kg BMI 25 kg/m 2 Warm moist skin, no active dermatoses, (+) jaundice Pink palpebral non hyperemic conjunctivae, icteric sclerae, pupil 3 to 4 mm ERTL, (-) eye discharge No nasoaural discharge, midline septum, (-) mass Moist buccal mucosa, non hyperemic posterior pharyngeal wall, no tonsillar enlargement No tragal tenderness, non-hyperemic external auditory meatus Supple neck, thyroid not enlarged, no distended neck veins, no palpable cervical lymphadenopathies

13. No chest deformities or asymmetry; no tenderness nor palpable masses, symmetrical chest expansion, equal vocal and tactile fremiti, clear breath sounds

14. JVP 3cms at 30° CAP rapid upstroke and gradual downstroke

15. Flabby abdomen, soft, (+) whitish striae, normoactive bowel sounds, (+) murphy’s sign, (-) CVA tenderness, (-) mass

16. Pulses full and equal, no cyanosis, no edema No tenderness of joints, no swelling, no limitation in ROM

17. Mental Status: conscious, coherent, oriented to time place and person, awake, follows commands GCS 15 (E4V5M6) Cranial nerves: (-) anosmia, pupils 3-4mm ERTL, OD no visual field cuts, EOM movement intact, OD; V1V2V3 intact, can raise eyebrows, can smile, can frown, intact gross hearing, uvula midline, can shrug shoulders, can turn head side to side against resistance, tongue midline on protrusion MMT 5/5 on all extremities, can do FTNT and APST (-) Babinski’s sign, (-) Nuchal Rigidity, (-) Kernig’s sign, (-) Brudzinki’s sign

18. Obstructive jaundice secondary to cholelithiases

19. Open cholecystectomy with IOC