SILLIMAN UNIVERSITY MEDICAL SCHOOL

SUBMITTED TO: Dr. Walden Ursos

SUBMITTED BY: Celine Veneria F. dela Cruz

REPRESENTATIVE CASE
1) IDENTIFYING DATA: A. R., 53 years old, male, married, Filipino, businessman, born on May 1, 1957 from Manjuyod,
Negros Oriental.
2) CHIEF COMPLAINT: Right Upper Quadrant Pain
3) MEDICAL HISTORY

A)HISTORY OF PRESENT ILLNESS:

4 days PTA, patient had a sudden onset of right upper quadrant pain radiating to the back characterized as
numbing with a pain scale of 3/10 occurring around 30 minutes after lunch which was fatty pork with rice. Patient also
noted an intermittent undocumented fever. This was not associated with nausea, vomiting, chest pain and diarrhea.
Patient tolerated the symptoms and took no medications. No consult done. Patient claimed the pain resolved
spontaneously.
2 days PTA, there was a recurrence of right upper quadrant pain scale of 4-5/10 and occurring around 45-50
minutes after intake of pork with fat and rice for lunch. This prompted the patient to seek consult from a local private
hospital and laboratory tests for TB, DB, IB and SGPT were ordered. Ultrasound of the abdomen was also done. Patient
claimed he was given pain medication via heplock.
1 day PTA, patient sought consult for interpretation of laboratory test results done the day prior at the private
hospital. The laboratory test revealed elevated TB, IB, DB and SGPT levels. The ultrasound of the whole abdomen
showed hepatic steatosis with fat sparing areas, hepatic cyst, gallbladder adenomyomatosis with cholelithiasis. Patient
was prescribed with Ampicillin + Sulbactam (SILGRAM) 750mg 1 tablet BID for 14 days and Tramadol + Paracetamol
(ALGESIA) 37.5mg PRN for pain. Patient was then referred to this institution for further management, thus this
admission.

B) PAST MEDICAL HISTORY:

Patient claims complete childhood immunizations. He has no known food and drug allergies. He is a known
hypertensive with maintenance medication of Losartan 50mg 1 tab OD (Diagnosed November 30,2020). He is non-
diabetic and non-asthmatic. No previous surgeries and previous hospital admissions.
C)FAMILY HISTORY:
Patient has no heredofamilial diseases at the maternal side. Patient has a family history of hypertension and
arthritis from the paternal side. He is the 3rd child among 7 children. His first and fourth siblings has arthritis.
D)PERSONAL AND SOCIAL HISTORY:

Patient is a non-smoker and an occasional alcohol-containing beverage drinker consuming 1-2 bottles of beer on
special occasions with his last intake on November 19, 2020. His diet is mostly composed of red meat pork and rice.
Patient manages his business during most of the day. He claims no illicit drug use and no recent travel history.

REVIEW OF SYSTEMS PHYSICAL EXAMINATION

General: No recent weight loss, no loss of
appetite
Skin: No pruritus, no petechiae, no rashes
Eyes: No eye pain, no diplopia, no blurring
of vision
Ears: No ear pain, no tinnitus, no
discharges
Nose: No coryza, no congestion, no
epistaxis
Mouth: No bleeding of gums, no ulcers
Throat: No sore throat, no dysphagia
Neck: No pain, no stiffness
Breasts: No gynecomastia
Respiratory: No cough, no hemoptysis, no
dyspnea
Cardiovascular: No chest pain, no
palpitation, no orthopnea
General Survey: Patient is awake, alert and not in respiratory distress
Vital Signs:
Height: 187 cm Weight: 50.7 kg BMI: 20.6 BP: 130/80 mmHg
Temperature: 36.0C RR: 20 cpm PR: 70 bpm O2 sat: 98% at room air
Skin: No pallor, no jaundice, no cyanosis, no active lesions, warm to tough, good skin turgor
Head: Normocephalic, atraumatic, hair fine and evenly distributed, no mass
Eyes: Anicteric sclerae, pink palpebral conjunctiva, no retroorbital pain
Ears: No active lesions, no discharges, no tenderness
Nose: Nasal septum midline, no tonsillopharyngeal congestion
Mouth: uvula midline, pink lips and gums, tonsils normal size
Neck, Axilla and Breasts: Supple neck, no neck vein engorgement, no lymphadenopathies
Chest and lungs: Symmetric, equal chest expansion, equal tactile fremitus, lungs resonant, clear breath sounds
Cardiovascular: adynamic precordium, PMI at 5 th LICS MCL, regular rate and rhythm, no murmurs, no heaves and
thrills
Gastrointestinal: No abdominal pain, no
nausea, no vomiting, no diarrhea, no
constipation
Genitourinary: No dysuria, no hematuria
Musculoskeletal: No arthralgia, no myalgia
Nervous system: No tremors, no seizures,
no syncope
Hematologic: No heavy bleeding, no easy
bruising
Endocrine: No polyphagia, no polydipsia,
no cold/heat intolerance
Abdomen: flabby, soft abdomen, tender at RUQ, no mass/organomegaly, tympanitic, normoactive bowel sounds,
(+) Murphy's sign, liver span 8cm
GUT: (-) CVA tenderness, bilaterally
Extremities: no gross deformities, strong peripheral pulses, CRT <2s
NERVOUS SYSTEM
MSE: Patient is conscious, coherent and oriented to time, person, and place
Cranial Nerve Evaluation:
CN1: able to smell alcohol, bilaterally
CN2: PERRLA
CN3,4,6: primary gaze midline, (-) strabismus, (-) ptosis, (-) nystagmus, full EOMs
CN5: (+) corneal reflex, facial sensory intact
CN7: able to smile and frown symmetrically
CN8: good hearing acuity
CN9,10: (+) gag reflex
CN11: able to shrug shoulders against resistance
CN12: tongue at midline, (-) tongue atrophy

Motor: 5/5 in all extremities

Sensory: 100% in all extremities
DTRs: All 2+
Meningeals: (-) nuchal rigidity, (-) Brundzinski's sign
Cerebellars: (-) gait ataxia, (-) dysmetria, (-) dysdiadokokinesia
PRIMARY WORKING IMPRESSION
DIAGNOSIS RULE IN RULE OUT
Acute  Right upper quadrant pain radiating to the back CANNOT BE RULED OUT
Cholelithiasis to  Fever
consider Acute  Leukocytosis (16,000/cumm)
Cholecystitis  High Fat diet
 Increasing Age
 Increased Total Bilirubin, Direct Bilirubin
 Ultrasound of the whole abdomen Hepatic steatosis with fat sparing
areas, hepatic cyst, gallbladder adenomyomatosis with cholelithiasis
III. DIFFERENTIAL DIAGNOSIS
DIAGNOSES RULE IN RULE OUT
Acute Viral  Right Upper Quadrant Pain  (-) Jaundice
Hepatitis  Fever  (-) Hepatomegaly
 Increased SGOT  (-) Splenomegaly
 Increased Alkaline Phosphatase  (-) IgM to Hepatitis A
antigen  Nonreactive
 (-) Antibody to Hepatitis
C virus  Nonreactive
 (-) HbsAG
Nonreactive
Acute Pancreatitis  Cholelithiasis on Ultrasound of Abdomen  (-) BMI >30
 Abdominal Pain radiating to the back  (-) Age >60 years old
 (-) Tachycardic
 (-) Tachypneic
 (-) Cullen’s sign
 (-) Turner sign
 Normal amylase
 Normal serum
Creatinine
Peptic Ulcer  Abdominal Pain  (-) Gradual
Disease  Pain 90 minutes to 3 hours after a meal  (-) Epigastric Burning
Abdominal pain
 (-) Tachycardia
IV. RATIONAL LABORATORY & DIAGNOSTIC TESTS
PATIENT NORMAL
LAB. TEST INTERPRETATION/NECESSITY AVAILABILITY COST
RESULTS VALUES
HEMATOLOGY
Hemoglobin 15.30% 13-16% Patient has an increased WBC count which SUMC, HCH, ACE, Php 300
Hematocrit 45% 42-50% indicates current inflammation correlating to Polymedic
White blood cells 16400/cumm 4500- our primary impression of acute cholecystitis
11000/cumm wherein according to Harrisons, a mild to
Segmenters 76% 55-70% moderate leukocytosis (12,000–15,000
Lymphocytes 15% 20-35% cells/mm3) is usually present. Other
Eosinophils 1% 1-4% parameters are within the normal range.
Monocytes 8% 1-6%
Basophils 0% 0-1%
Platelet Count 206T/ cumm 150-
400T/cumm
Red blood cell 5M/cumm 4.6-
count 6.2M/cumm
MCV 90fl 80-96fl
MCH 30.60pg 27-31pg
MCHC 34% 33-36%
BLOOD CHEMISTRY
Total Bilirubin 3.8 mg/dl 0.1-1.2 mg/dl There is an increased total bilirubin and Php 200
Direct Bilirubin 3 mg/dl 0.10-0.40 direct bilirubin probably because of the Php200
mg/dl cholelithiasis obstructing the gallbladder thus SUMC, HCH, ACE,
Indirect Bilirubin 0.80 mg/dl Less than 0.81 presenting post hepatic hyperbilirubinemia, Polymedic Php200
AST 258 mg/dl 8-38 mg/dl an increased AST and alkaline phosphatase Php200
Serum Creatinine 1 mg/dl 0.7-1.4 due to liver inflammation. Php250
Serum Albumin 4.30 mg/dl 3.5-5.0 Php300
Sodium 143.70 meq/L 135-145 Php700
Potassium 3.60 meq/L 3.6-5.0 Php700
Alkaline 156 U/L 38-126 Php450
Phosphatase
Amylase 59 U/L 30-110 Php450
IMMUNOLOGY
HbsAG Nonreactive Nonreactive Patient has normal SUMC, HCH, ACE, Php 1500
IgM antibody to Nonreactive Nonreactive results. Polymedic Php 1500
Hepatitis C antigen
Antibody to Nonreactive Nonreactive Php 1500
Hepatitis A antigen
IMAGING STUDIES
Ultrasound of the Hepatic steatosis with fat sparing This result may be associated with the SUMC, HCH, ACE, Php 2500
abdomen areas, hepatic cyst, gallbladder patient’s high fat containing diet and acute Polymedic
adenomyomatosis with cholecystitis causing adenomyomatosis due
cholelithiasis to the obstruction caused by the
cholelithiasis.
PATHOPHYSIOLOGY

V. THERAPEUTIC MANAGEMENT
LIST OF PROBLEMS THERAPEUTIC OBJECTIVES

ADVICE AND INFORMATION NON-PHARMACOLOGIC MANAGEMENT

PHARMACOLOGIC MANAGEMENT
DRUG NAME EFFICACY SAFETY SUITABILITY

P-DRUGS
DRUG NAME EFFICACY SAFETY SUITABILITY COST

VI. MONITORING AND FOLLOW-UP

VII. PRESCRIPTION WRITING

JUAN DE LA CRUZ MD
REFERENCES:
Silliman University Medical Center

Patient: X,X Date: 09-28-14

Address:Dumaguete City Age/Sex: 26yo/F

JUAN DE LA CRUZ MD
Lic. No. 0123456