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

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

Abdominal pain

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

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

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

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

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

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

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

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

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 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

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

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

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

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

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

Obstructive jaundice secondary to cholelithiases

Open cholecystectomy with IOC

Ultrasound initial investigation noninvasive, painless, no radiation dependent upon the skills and the experience of the operator

Biliary Radionuclide Scanning (HIDA Scan) a noninvasive evaluation of the liver, gallbladder, bile ducts, and duodenum with both anatomic and functional information diagnosis of acute cholecystitis, which appears as a nonvisualized gallbladder, with prompt filling of the common bile duct and duodenum

Computed Tomography differential diagnosis of obstructive jaundice

Percutaneous Transhepatic Cholangiography An intrahepatic bile duct is accessed percutaneously with a small needle under fluoroscopic guidance. it defines the anatomy of the biliary tree proximal to the affected segment useful in patients with bile duct strictures and tumors

Magnetic Resonance Imaging provides accurate anatomic details of the liver, gallbladder, and pancreas similar to those obtained from CT

Endoscopic Retrograde Cholangiography requires intravenous sedation for the patient include direct visualization of the ampullary region and direct access to the distal common bile duct, with the pos the diagnostic and often therapeutic procedure of choicesibility of therapeutic intervention Complications include pancreatitis and cholangitis, and occur in up to 5% of patients.

Cholecystostomy applicable if the patient is not fit to tolerate an abdominal operation

Cholecystectomy most common major abdominal procedure Laparoscopic Cholecystectomy minimally-invasive procedure, minor pain and scarring, and early return to full activity. treatment of choice for symptomatic gallstones Open Cholecystectomy safe and effective treatment for both acute and chronic cholecystitis

Intraoperative Cholangiogram The bile ducts are visualized under fluoroscopy by injecting contrast through a catheter placed in the cystic duct. Their size can then be evaluated, the presence or absence of common bile duct stones assessed, and filling defects confirmed, as the dye passes into the duodenum.

Choledochal Drainage Procedures stones cannot be cleared and/or when the duct is very dilated (larger than 1.5 cm in diameter) Choledochoduodenostomy performed by mobilizing the second part of the duodenum (a Kocher maneuver) and anastomosing it side to side with the common bile duct