[ACCM]

History

Particulars

Name: Mrs. Shrestha
Age: 30 years Sex: Female
Religion: Hindu
Education: SLC
Occupation: Housewife
Marital Status: Married, with 2 children
Address: Sinamangal
Date of admission: 31/10/2006
Mode of Admission: OPD
Date of examination: 31/10/2006

Chief Complaints
• 2nd post operative day with slight pain in the wound sight.

History of Present Illness (HOPI)
The patient complains of slight pain in the wound site. According to the patient she was apparently well 1 month back then she had pain in the right upper abdomen. The pain was,
• Colicky type
• Moderate in severity
• Aggravated by oily and spicy food and relieved by rest
• Radiated to back and right shoulder.

The pain was associated with vomiting, the vomiting was
• 1-2 episode a day only 3 days back
• Amount was about 100 ml in each episode
• Vomitus contained food particles
• Yellow in color
• Non projectile type
• Bitter in taste
• No foul smell
• No blood stain

There is no history of fever, cough, difficulty in breathing, jaundice, burning micturation and loose motion.

She passed flatus after seven hours; liquid diet was started twelve hours after operation and she has returned to her normal bowel and bladder habit.

In systemic review, she doesn’t have any difficulty in her daily activities like shortness of breath, cough, palpitation, any glandular enlargement, itching, swelling of limbs, epilepsy etc.

Past History
No history of hypertension, diabetes, asthma, tuberculosis, jaundice, any past surgery and blood transfusion

Menstrual History
K=14 {(3 - 7 days)/(28 ± 7 days)
• Dysmenorrhoea absent
• Clots present

Obstetric History
• Age at marriage: 20 years
• P2
• LMP: 26/10/2006
• No history of abortion or still birth.
• No contraceptives history.

Personal History
• Bowel: Disturbed (Constipated)
• Appetite: Normal
• Sleep: Normal
• Urine: Normal
• Non Vegetarian
• Non smoker
• Does not consume alcohol

Family History
No history of Hypertension, Asthma, Tuberculosis, Infectious diseases and past surgery in the family members.

Socioeconomic History
She is a housewife, there are six family members, joint family with good housing condition and safe drinking water, toilet facility is present and the family fall in the middle class.

Drug & Allergy History
There is no known history of allergy to drugs, dust and food.

Clinical Examination

A. General Examination

1. General Characteristics
• Appearance: Ill looking
• Co-operation: Cooperative
• Body built: Well built
• Decubitus: Supine
• Nutritional status is good
• Intravenous cannula in situ in the left hand.

Pallor – Not present
Icterus – Not present
Lymphadenopathy – Not present
Leuconychia – Not present
Clubbing – Not present
Cyanosis – Not present
Oedema – Not present
Dehydration – Hydration status is good.

2. Vitals
Pulse: 72/min.
Blood pressure: 120/80 mm of Hg
Respiration: 18/min.
Temperature: 97ºF
JVP: not raised

Input Output Chart
Input
Ringers Lactate (500 ml) x 3 = 1500 ml
5% Dextrose (500 ml) x 2 = 1000 ml
Total = 2500 ml in last 24 hours.
Output
Urine = 1865 ml in last 24 hours.

B. Local Examination

Wound
• Site: Right subcostal hypochondrium
• Size: 4 cm., transverse
• Temperature: Not raised
• Tenderness: Present
• Discharge: Absent
• Suture material in situ
• Drain in situ

C. Systemic Examination

Abdominal Examination

Inspection
• Scaphoid in shape.
• All quadrants moving with respiration.
• Dressing at the wound site
• Umbilicus centrally placed and inverted.
• No visible swelling in any quadrant.

Palpation
Superficial Palpation: Temperature not elevated, slight tenderness in the wound site only. No superficial mass and lymph node was felt.
Deep Palpation
• Liver, spleen were not palpable

Percussion
• Tympanic sound heard over the abdomen
Auscultation
• Normal bowel sound heard

Respiratory system: Bilateral vesicular sound heard, no added sound

Cardiovascular System: First and second heart sound heard, no murmur.

Central Nervous System: Intact

Provisional Diagnosis
2nd post operative day of cholecystectomy with slight pain in the wound sight.

Differential Diagnosis
• Acute Cholangitis
• Acute Pancreatitis
• Acute Hepatitis
• Perforated Viscus eg. Peptic ulcer
• Appendicitis
• Right lower lobe pneumonia

Investigation
• Blood: Hb%, TC, DC, ESR
• Abdominal X-ray
• Ultrasonograph

Final Diagnosis

Management

Source: Angel's CONCISE CLINICAL METHODS