1. Jesus Martin Generoso, Jr.

2.  FR, 50 male  Married  Roman catholic  Mandaluyong  Informant: patient and wife, poor to fair reliability  Admitted February 19, 2011

3.  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

4.  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

5.  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.  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.

7.  2 days PTA – consulted  Jaundiced, tea-colored urine, icteric sclerae, sallow skin.  t/c hepatitis  For concurrent lab work up and ultrasound

8.  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 – nonreactive  Alk Phos – 204 u/l (35 -130)

9.  (-) 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

10.  (+) 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 disorders  No previous operations

11.  (+) HTN  (-) DM, (-) TB, (-) gall stones, (-)allergies

12.  Married, with 4 kids  Jeepney driver for 30 years  Denies alcohol and cigarette consumption  No hazardous chemical exposure  Fond 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

13.  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

14. VITAL SIGNS  BP 110/70  HR 94  RR 23  Temp 38.7 GENERAL SURVEY  Seen lying down  Awake, alert, coherent  In distress  With chills

15. SKIN  Slightly sallow  No cyanosis  Good turgor HEENT  Icteric sclerae, pale palpebral conjunctiva  (-) CLAD, (-) TPC, trachea is midline

16. CARDIAC  Adynamic precordium  No heaves or thrills  Apex at 5 th ICS LMCL  Tachycardic RESPIRATORY  Symmetric chest expansion  Resonant lung fields  With slight/occasional crackles both lung bases  (-) wheezes, (-) rhonchi  (-) decreased breath sounds

17. 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

18. 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

19.  Cholecystolithiasis and choledocholithiasis, in probable ascending cholangitis; r/o gallstone pancreatitis  Hypertension stage II, level of control unknown

20. Differentials

21. 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

22. RULE IN  Abdominal pain  Diet of the patient  Increased alkaline phosphatase RULE OUT  Gall bladder wall not thickened on UTS  Questionable murphy’s sign

23. 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

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