Cholelithiasis

28/F ASR

Chief Complaint: Abdominal Pain

History:
• >2 years PTA, patient had intermittent abdominal pain of 3/10 RUQ and epigastric area
usually triggered after eating a full meal. No consult done and no medications taken.
• 3 months PTA, patient sough consult at a local clinic where a whole abdomen
ultrasound was done showed cholelithiases with no signs of cholecystitis. She was then
advised surgical intervention but due to COVID-19 pandemic, opted to delay procedure.
• 1 week PTA, there was now progression of intermittent RUQ pain now with increased
frequency of attacks prompting consult. She was then advised to undergo
cholecystectomy and was then referred to our institution

***No hx of acholic stools and tea-colored urine

PMH – hypertensive, on telmisartan 40mg/tab 1 tab OD

FH – DM type 2, HTN, no history of cancer

PE
Awake, afebrile
No jaundice
Anicteric sclera
Flabby abdomen, no gross lesions seen, normoactive bowel sounds, soft, nontender abdomen,
no murphy’s sign
BP 140/90
PR 80
RR 20

Laboratories/Imaging

Whole abdomen ultrasound

Impression
Fatty infiltration of the liver
Cholelithiasis with no signs of cholecystitis
Unremarkable study of the Pancreas, Spleen, Abdominal Aorta, Kidneys, and Urinary Bladder
Normal sized uterus with intact endometrial stripe

COVID-19 RT PCR Test - Negative

CBC
Hgb 14.0
Hct 0.41
Wbc 8.1
Seg 0.63
Lympho 0.36
Mono 0.01
Plt 418

Na 137.80
K 3.72

PTT 28.9
INR 1.020
PT 12.2
% activity 85%

Chest Xray – Normal Chest

Admitting diagnosis – Chronic Calculous Cholecystitis

For Open Cholesystectomy