dr_messo
05-04-2002, 12:11 AM
S E A 35 year-old Saudi female patient known case of gall stone admitted to the hospital through E.R yesterday complaining of R.U.Q & right shoulder pain since one month wich become sever yesterday .
History of Presnting Illness :
R.U.Q PAIN :
Pain attacks increase during the last month every 2-3 days for about 1 hour duration .
· Sudden onset .
· Progressive .
· Become so sever yesterday .
· Colicky .
· Radiate to right shoulder & epigastric area .
· Pain is on & off .
· No associated symptoms .
· No agrevating factors .
· Relived by drugs ( yellow rounded tablets ) .
· No H/O fever , nausea , vomiting , change in bowel habits , jaundice , melena , edema , hematechezia , tensemus or heart burn .
Past medical history :
· cesarean section before 3 years .
· Patient on oral contraceptive for about 10 years .
· Also using thyroxin 100 mg since 3 years .
· Known case of gall stone .
· No history of, D.M , HTN , T.B , rheumatic fever , surgery , or ischemic heart disease .
Allergies :
· No H/O drug , food , animal or occupational allergy .
Social history :
· Married with 6 children 4 boys & 2 girls younger is 2 years & older is 15 .
· Living with her family in owened building .
· No H/O smoking, alcohol or drug abusing .
Family history :
· No family history of HTN , DM , C.V.A , ischemic heart disease , asthma , malignancy or death of young relatives .
Review of systems :
Endocine system :
Patient is hypothyrodism using thyroxine 100 mg tablets daily .
· NO other SIGNIFICANT SYMPTOMS .
On examination:
· The patient was conscious , cooperative , oriented to time, person & place .
· Look well , mormal body built , ling comfortably on bed .
· Not jaundice , cyanosed .
· Afebrile .
· Vitals :
o P.R = 85 /min . regular , normal volume , no femoral delay , collapsing pulse ,syncronus also blood vessel wall was not palpable .
o R.R = 16/ min .
o B.P = 110 / 70 mmHg .
o Temp. = 36.9 C .
· Head :
o Eyes were normal no pallor or jaundice .
o Tounge was normal , no central cyanosis or abnormal coloration .
o Lips were also normal color , no perephral cyanosis .
· Neck :
o No lymph node enlagment , normal J.V.P , normal thyroid , normal carotid , trachea was not displaced .
· Hands :
o No clubbing , leuconychia , koilonychias , splinter hemorrhage , palmar erythema , tremor , waisting , swilling or deformity .
· G.I.T :
o Normal contour .
o No, promenant veins , hernia scar , scrach mark , hair distribution , pigmentation , rigidity , organomegaly or ascitis .
o Normal liver span , spleen was not palpable .
o No other significant ( remarkable )findings .
Investegations :
· WBC 7.6 .
· RBC 4.01 LOW
· Hb 11.5 low .
· HCT 32.8 low .
· MCH 28.7
· MCHC 35.0
· RDW 11.9
· GLU 94 mg/dl
· Na 136
· K 4
· GOT 22
· ALP 12
· CPK 71
· LDH 270
· AMYL 41
Deferential diagnosis :
· Cholecystitis .
· Pancereatitis
· Peptic ulcer .
· Hiatus hernia .
· Hepatic flexure carcinoma .
· Cardiopulmanry disease .
History of Presnting Illness :
R.U.Q PAIN :
Pain attacks increase during the last month every 2-3 days for about 1 hour duration .
· Sudden onset .
· Progressive .
· Become so sever yesterday .
· Colicky .
· Radiate to right shoulder & epigastric area .
· Pain is on & off .
· No associated symptoms .
· No agrevating factors .
· Relived by drugs ( yellow rounded tablets ) .
· No H/O fever , nausea , vomiting , change in bowel habits , jaundice , melena , edema , hematechezia , tensemus or heart burn .
Past medical history :
· cesarean section before 3 years .
· Patient on oral contraceptive for about 10 years .
· Also using thyroxin 100 mg since 3 years .
· Known case of gall stone .
· No history of, D.M , HTN , T.B , rheumatic fever , surgery , or ischemic heart disease .
Allergies :
· No H/O drug , food , animal or occupational allergy .
Social history :
· Married with 6 children 4 boys & 2 girls younger is 2 years & older is 15 .
· Living with her family in owened building .
· No H/O smoking, alcohol or drug abusing .
Family history :
· No family history of HTN , DM , C.V.A , ischemic heart disease , asthma , malignancy or death of young relatives .
Review of systems :
Endocine system :
Patient is hypothyrodism using thyroxine 100 mg tablets daily .
· NO other SIGNIFICANT SYMPTOMS .
On examination:
· The patient was conscious , cooperative , oriented to time, person & place .
· Look well , mormal body built , ling comfortably on bed .
· Not jaundice , cyanosed .
· Afebrile .
· Vitals :
o P.R = 85 /min . regular , normal volume , no femoral delay , collapsing pulse ,syncronus also blood vessel wall was not palpable .
o R.R = 16/ min .
o B.P = 110 / 70 mmHg .
o Temp. = 36.9 C .
· Head :
o Eyes were normal no pallor or jaundice .
o Tounge was normal , no central cyanosis or abnormal coloration .
o Lips were also normal color , no perephral cyanosis .
· Neck :
o No lymph node enlagment , normal J.V.P , normal thyroid , normal carotid , trachea was not displaced .
· Hands :
o No clubbing , leuconychia , koilonychias , splinter hemorrhage , palmar erythema , tremor , waisting , swilling or deformity .
· G.I.T :
o Normal contour .
o No, promenant veins , hernia scar , scrach mark , hair distribution , pigmentation , rigidity , organomegaly or ascitis .
o Normal liver span , spleen was not palpable .
o No other significant ( remarkable )findings .
Investegations :
· WBC 7.6 .
· RBC 4.01 LOW
· Hb 11.5 low .
· HCT 32.8 low .
· MCH 28.7
· MCHC 35.0
· RDW 11.9
· GLU 94 mg/dl
· Na 136
· K 4
· GOT 22
· ALP 12
· CPK 71
· LDH 270
· AMYL 41
Deferential diagnosis :
· Cholecystitis .
· Pancereatitis
· Peptic ulcer .
· Hiatus hernia .
· Hepatic flexure carcinoma .
· Cardiopulmanry disease .