| Post Operative Case Of Cholecystectomy -
13-12-2006, 01:35 PM
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 doesnt 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: 97ΊF
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
Last edited by ACCM : 13-12-2006 at 02:17 PM.
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