DAVAO MEDICAL SCHOOL FOUNDATION

COLLEGE OF MEDICINE
DEPARTMENT OF SURGERY

Name of Student: DANIELLE M. PASTERA

Section: NMD 3
Date: SEPT. 22, 2021
Group No. / Preceptor: DR. JETHRO SALVANA

Case Study:
Patient: C.B.,a 38 year old female, Filipino, wet market vendor from Davao presented to the emergency
room with a chief complaint of abdominal pain of 6 months duration.

TASK
Enumerate the salient features of
this case:
What is your primary impression?
Justify your answer why you
considered such a primary
impression. ANSWER IN
SENTENCE FORM.
ANSWER
● Patient is female with a chief complaint of abdominal pain 6
months of duraton.
● 6 months prior to consultation the patient felt intermittent
abdominal tenderness.
● 4 months prior to consultation the patient felt an intermittent
colicky pain with a pain scale of 5/10. This was noted after
having a heavy buffet meal.
● The symptoms recurred after 2 weeks.
● On ultrasound examination: Thickened walls of the
gallbladder with gallbladder stones.
● Physical exam of the abdomen revealed a positive murphy’s
sign with a distended abdomen.
● The patient was in respiratory distress.
My impression on this case is that the patient has a chronic
cholecystitis.
I consider this as the primary impression of the case because of the
signs and symptoms that were noted during the initial medical
history such as intermittent abdominal tenderness, intermittent
colicky pain after having a heavy buffet meal. This was confirmed
during the abdominal ultrasound where a gallbladder stone was
found as well as a thickening on the gallbladder wall and also a
positive Murphy’s sign during the physical examination.

DIFFERENTIAL DIAGNOSES

1. Acute cholecystitis
Rule-in: Rule-out: REFERENCE
The patient history compatible with acute This diagnosis is ruled out because the Schwartz
cholecystitis there was fatty food intolerance patient did not experience unremitting Principles of
and gallstones were found on ultrasound pain, instead the patient felt well in Surgery
between attacks. The patient was also
afebrile upon admission. In acute
cholecystitis the patient often complains
of anorexia and is reluctant to move
because of the pain, this was not noted on
the patient.
2. Gastroesophageal reflux disease
Rule-in: Rule-out: REFERENCE
The patient felt abdominal bloatedness and This diagnosis is ruled out because of the Schwartz
with intermittent colicky epigastric pain. ultrasound finding of gallstones and Principles of
Antacids gave relief but only temporarily. gallbladder inflammation. The patient did Surgery
not complain of heartburn, regurgitation,
and dysphagia.
3. Acute pancreatitis
Rule-in: Rule-out: REFERENCE
The patient felt intermittent bloatedness as well This diagnosis is ruled out because edema Schwartz
as colicky epigastric pain after eating a heavy was not noted on the patient. Also, Principles of
buffet meal. There was also the presence of according to Ranson’s criteria, an age of Surgery
gallbladder stones and inflammation of greater than 55 years old is the age usually
gallbladder wall, this oftentimes occur together associated with this disease, in this case
with acute pancreatitis. the patient was 38 years old.

FINAL IMPRESSION:
My final impression on this case is that the patient has chronic cholelithiasis, this is because the
medical history, the signs and symptoms, as well as the laboratory imaging coincided with the
characteristics of the disease. The noted signs and symptoms were intermittent abdominal bloatedness,
colicky epigastric pain and a positive Murphy's sign during physical examination, aan ultrasound imaging
that showed gallbladder inflammation and gallstones, although these signs and symptoms are not
pathognomonic for chronic cholecystitis, they are almost always present with the said disease. The gender
of the patient also predisposes a risk of developing cholecystitis. Fever is also rarely present, and the
patient was afebrile on admission. To strengthen my diagnosis, I would request for CBC and liver function
tests to rule out acute cholecystitis that would usually present with leukocytosis and sometimes an
elevated bilirubin level.

MANAGEMENT OPTIONS:
The management option for this case is prompt cholecystectomy preferably the laparoscopic
approach, because the patient is diabetic and the risk for developing a severe acute cholecystitis is high.
This operation can also give best long term results. While waiting for surgery, the patient should be
advised to avoid the consumption of fatty food and very large meals,