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GS III Preceptorials

GS III Preceptorials. January 28, 2012 Block 10a. General Data. 55 y.o. Male Farmer Roman Catholic Lubang Island, Occidental Mindoro Chief Complaint: RUQ abdominal pain. History of Present Illness. Recurrence of:

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GS III Preceptorials

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  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. 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. History of Present Illness 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. Physical Examination

  10. Physical Examination

  11. Assessment Cholelithiasis

  12. Laboratory CBC • Hgb 158 • Hct 0.490 • WBC 6.8 • Plt 296 • Monocytes 0.07 • Eosinophils0.03 • Basophils 0.00 • Neutrophils 0.56 • Lymphocytes 0.34

  13. Laboratory • Glucose 5.40 mmol/L • BUN 4.50 mmol/L • Creatinine 83.6 umol/L • Na 139 • K 3.9 • Cl 105

  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

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