Jesus Martin Generoso, Jr.

FR, 50 maleMarriedRoman catholicMandaluyong Informant: patient and wife, poor to

fair reliabilityAdmitted February 19, 2011

5 weeks PTA Nonradiating intermittent epigastric pain,

5-6/10, “kumikirot” No specific timing or setting, no

aggravating factors, no other associated symptoms

Temporarily and partially relieved by aluminum/magnesium hydroxide (antacid, Kremil-S)

No consult done Abdominal pain persisted

2 weeks PTA Increase in intensity of intermittent

epigastric pain to 9-10/10, radiating to the back, “sinasaksak”

No noted aggravating/relieving factors, no specific timing or setting

Consult was done at the ER, diagnosed with ulcer, given lansoprazole

1 week PTA Still with the noted more intense

epigastric pain Consult was done at ER, was given

lansoprazole, diagnosed with PUD, sent home

CBC•HGB – 114 (dec)•HCT 0.36 (dec)•WBC 14.0 (inc)

•Segmenters 0.85•Lymphocytes 0.15

•Platelets adequate

Urinalysis •Bacteria – moderate•Epithelial cells - moderate

6 days PTA Undocumented remittent high-grade fever Developed yellowing of the skin, urine like

aced tea, and ash-colored stools Still with intense abdominal pain or same

previous character 2 days PTA – consulted

Jaundiced, tea-colored urine, icteric sclerae, sallow skin.

2 days PTA – consulted Jaundiced, tea-colored urine, icteric

sclerae, sallow skin. t/c hepatitis For concurrent lab work up and

ultrasound

UTS of liver, gall bladder, biliary tree Gallbladder wall not thickened Fatty liver Obstructing choledocolithiasis and

cholecystolithiasis with secondary biliary dilatation

SGPT 77.6 u/l (0-40)SGOT 52.9 u/l (0-40)Anti HAV IgM and IgG – nonreactiveAlk Phos – 204 u/l (35 -130)

(-) diarrhea, (-) vomiting, (-) constipation, (-) chills, (-) weight loss, (-) cough and colds, (-) easy bruisability, (-) trauma, (-) melena, (-) hematochezia, with occasional ascending retrosternal pain associated with sour/bitter taste in mouth

Diagnostics were followed-up ,hence admission

(+) HTN highest BP 160/110, unknown usual BP Maintained with Losartan 50 mg OD,

amlodipine 5 mg OD (+) urolithiasis, unrecalled details (-) DM, (-) asthma, (-) TB, (-) CA, (-)

allergies, (-) bleeding disordersNo previous operations

(+) HTN (-) DM, (-) TB, (-) gall stones,

(-)allergies

Married, with 4 kids Jeepney driver for 30 yearsDenies alcohol and cigarette consumptionNo hazardous chemical exposureFond of fatty and fried food, consumes 2-3

cups of rice per meal (2-3 meals per day), with some vegetables, not fond of coffee, likes to drink carbonated beverages

No exercise regimen

Cutaneous – no rashes HEENT – no headache, no dizziness, no blurring

of vision, no tinnitus, no epistaxis, no dysphagia, no throat pain

Cardiac – no orthopnea, no paroxysmal nocturnal dyspnea, no chest pain, no palpitations

Respiratory – no difficulty breathing, no hemoptysis

GU – no hematuria, no dysuria, no frequency, no retention

Extremities – no calf pain, no claudication Neurologic – no one-sided weakness, no loss of

consciousness

VITAL SIGNS

BP 110/70 HR 94 RR 23 Temp 38.7

GENERAL SURVEY

Seen lying down Awake, alert,

coherent In distress With chills

SKIN

Slightly sallow No cyanosis Good turgor

HEENT

Icteric sclerae, pale palpebral conjunctiva

(-) CLAD, (-) TPC, trachea is midline

CARDIAC

Adynamic precordium No heaves or thrills Apex at 5th ICS LMCL Tachycardic

RESPIRATORY

Symmetric chest expansion

Resonant lung fields With slight/occasional

crackles both lung bases

(-) wheezes, (-) rhonchi

(-) decreased breath sounds

ABDOMEN Globular No caput medusae Hypoactive bowel

sounds Tympanitic LUQ, RUQ,

LLQ; dull RLQ With epigastric direct

tenderness, with RUQ direct tenderness, murphy’s sign assessment questionable

EXTREMITIES

No cyanosis Pulses full and equal

HISTORY

50 M With epigastric pain

radiating to back Jaundice Fever UTS findings Laboratory findings

Increased alkaline phosphatase

PHYSICAL EXAMINATION

Tachycardic, tachypneic, febrile

Jaundiced With epigastric

tenderness

Cholecystolithiasis and choledocholithiasis, in probable ascending cholangitis; r/o gallstone pancreatitis

Hypertension stage II, level of control unknown

Differentials

RULE IN

Epigastric pain radiating to the back

With UTS of gallstones and stones in the biliary tree

Fever Jaundice Epigastric and RUQ

tenderness

CANNOT TOTALLY RULE OUT No symptoms of

malabsorption

RULE IN

Abdominal pain Diet of the patient Increased alkaline

phosphatase

RULE OUT

Gall bladder wall not thickened on UTS

Questionable murphy’s sign

RULE IN

Intermittent epigastric pain

With GERD symptoms Diet of the patient Epigastric tenderness

RULE OUT

Jaundice Abdominal pain with

no specific timing or setting

RUQ tenderness

Operation done: emergency open cholecystectomy IOC, and common bile duct exploration and T-tube insertion