Case presentation 

Presented by:

DR. FATIMA FARHANA

DR. SHEIKH MUHAMMAD ZAHID ANWAR
 Case History
PARTICULARS OF THE PATIENT:
• Name: Mrs. Jannatul Ferdous
• Age: 34 years
• Sex: Female
• Religion: Islam
• Marital status: Married 
• Occupation: Housewife
• Present Address: Tongi, Gazipur.
• Permanent Address: Sirajgang, Bangladesh.
• Ward- Female Surgery Paying Ward.
• Bed no- 05
• Date of admission: 01.08.2022
• Date of examination: 01.08.2022
CHIEF COMPLAINTS:
1. Pain in the right upper abdomen for 2
days.
2. Vomiting for 2 days.
3. Fever for 2 days .
HISTORY OF PRESENT ILLNESS:

According to patient’s statement, she was reasonably well 02

days back. Then she developed pain in the right upper abdomen,
which was sudden in onset, colicky in nature, severe in intensity,
aggravated by taking fatty meal and relieved by taking analgesic.
The pain radiated to the back and right shoulder region.
She also complained of vomiting for 2 days which was abrupt in
onset, bitter in taste and contained partially digested food
materials.
She also complaints of fever for same duration, which is low
graded, intermittent in nature and subsided by taking
paracetamol. 
She gave no history of periodicity of pain and the pain wasn’t
relieved by any change of position.
 With all this complaints she admitted to this hospital for
proper management.
                 
 HISTORY OF PAST ILLNESS :
She has no history of any similar illness or any kind of surgery.
Patient is normotensive, non-diabetic and non-asthmatic.

FAMILY HISTORY:
There is no significant family history of hypertension, DM, Bronchial
asthma. The number of family members
Click to ad text are four and all are healthy.

PERSONAL HISTORY:
She is non-smoker, non-alcoholic. She drinks safe boil water and
maintains proper hygiene. She has no history of taking alcohol
or betel leaf.
SOCIOECONOMIC HISTORY:
She belongs to a middle class family.

MENSTRUAL HISTORY:Click to add text

  1. Age of menarche: 13 years
  2. Menstrual cycle : Regular
  3. Menstrual period :  5 days
  4. LMP: 20 June, 2022 
IMMUNIZATION HISTORY:
She is immunized as per EPI schedule.

DRUG HISTORY:
She has a history of taking analgesic, paracetamol and anti-
ulcerant drugs before admission. 

ALLERGIC HISTORY:
She is not allergic to any food, environmental particles or any
drugs.
General Examination:
 Appearance- Ill looking
 Body built- Average
 Co-operation- Cooperative 
 Decubitus- On choice
 Nutrition- Average 
 Anemia- Absent 
 Jaundice- Absent 
 Cyanosis- Absent
 Dehydration- Absent
 Oedema- Absent
 Clubbing- Absent 
 Leukonychia -Absent
 Koilonychia- Absent
 Lymph nodes- Not palpable
 Neck vein- Not engorged 
 Neck glands- Not enlarged 
 Thyroid gland- Not enlarged 
 Skin conditions- Normal
 Bowel habit- Normal
 Bladder habit- Normal
 Ascites- Absent 

 Pulse- 74 beats/min

 Blood pressure- 120/70 mmHg

 Temperature- 98˚ F

 Respiratory rate-16 breaths/min

 Body weight- 56kg 

Local examination:

GASTROINTESTINAL SYSTEM:
Abdomen Proper :
 Inspection:  
• Size & shape of the abdomen: Scaphoid
• Umbilicus: Centrally placed & Inverted
• Skin condition: Normal; No scar mark
• Visible peristalsis :Absent
• Visible lump: Absent
• Visible pulsation: Absent
• Visible engorged veins : Absent
• Hernial orifice : Intact
 Palpation : 
        On superficial palpation- 
• Local temperature: Normal
• Tenderness: Present in right hypochondriac region
• Muscle guard: Present
• Murphy's Sign- Positive
• Palpable Lump: Absent 
On deep palpation- 
• Liver & spleen: Not palpable.
 • Kidney: Not ballotable
• Urinary bladder: Not palpable
 Percussion:
• Percussion note : Tympanic.
• Upper boarder of liver dullness: Present in the right 5 th
intercostal space on mid clavicular line.
• Shifting dullness : Absent.
• Fluid thrill : Absent
  Auscultation : 
Bowel sound- present.
D/R/E: Shows no abnormality.
SYSTEMIC EXAMINATION:
Genitourinary system ::
Sex: Female
Kidney: Not ballotable
Urinary bladder: Not palpable
Respiratory system:
Inspection : Size & shape of the chest is normal.
Palpation : Trachea is centrally placed.
Percussion : Percussion note is resonant.
Auscultation : Vesicular breath sound.
Cardiovascular system:
Pulse : 74 beats/min.
Blood pressure : 120/70 mmHg. 
JVP : Not raised.
Precordium : 

Inspection : Size & shape of the chest is normal.

Palpation : Apex beat is situated in left 5th
                   
intercostal space 9cm away from
             midline.

Auscultation : Heart sound = S1 + S2 + 0
Neck vein : Not engorged.
Nervous system:
Higher psychic function:
 Consciousness:  Hallucination:
Conscious  Absent.
 Orientation:
Oriented 
 Speech: Normal

 Memory: Intact

 Behavior: Normal

 Delusion: Absent
Motor Function: 
 Bulk of the muscle : Normal 
 Tone of the muscles : Normal

 Strength of the muscles : 5/5 

 Co-ordination of movements: Co-

ordinated 
 Gait: Normal

 Reflexes : Good
  Sensory Function:

Tactilesense: Intact
Position sense: Intact
Recognition sense: Intact
Vibration sense : Intact
Pain sense: Intact
     SALIENT FEATURES:

Mrs. Jannatul Ferdous , 34 years old, married, housewife,

hailing from Tongi, Gazipur was admitted in this hospital on
1st  August 2022 with the complaints of pain in the right
hypochondriac region for 2 days which was sudden in onset,
severe and colicky in nature, aggravated by taking fatty meal.
The pain radiated to the back and was referred to the tip of
the right shoulder. The pain was associated with vomiting
and fever. There was no periodicity of pain and it didn’t
relieve by any change of posture. Her bowel and bladder
habit is normal. She is non diabetic, normotensive, non-
asthmatic.
On general examination I found her ill looking, non-anemic,
non-icteric, vitals were normal & other findings were normal.
On local examination her abdomen was soft and tenderness
was present in right hypochondriac region. Murphy's sign
was positive. There is no palpable lump, any scar mark,
visible peristalsis, no organomegaly, no ascites. Percussion
note was tympanic and bowel sound was present. Other
systemic examination findings were normal.
Provisional Diagnosis :
PROVISIONAL DIAGNOSIS:
      Acute Cholecystitis

DIFFERENTIAL DIAGNOSIS:
 Acute exacerbation of duodenal ulcer
 Acute pancreatitis
Investigations:
1. CBC with ESR- 
              Hb%- 12.5 g/dl
              WBC- 13,000/cu.mm
              Neutrophil- 80%
              Lymphocyte- 30%
              RBC- 4.42 million/cu.mm
              Platelet- 2,40,000/cu.mm
2. USG of whole abdomen with special attention to hepatobiliary system
and pancreas-
 Liver – Normal in size and homogenous in echotexture No focal lesion
is seen. Intra and extra-hepatic biliary channels are not dilated.
 Gall bladder- Distended. Multiple tiny bright echogenic structures with
posterior acoustic shadows are seen within the lumen of GB.Wall is
thick (8.1mm) & hypoechoic. Mild peri-cholecystic collection is seen.
 Pancreas- Normal in size & echogenicity is homogenous
 Kidney- Both kidneys are normal in size, shape & echogenicity
 Bladder- Is well filled with smooth & regular structures
3. S. Bilirubin (total)-   0.54 mg/dl           ( normal range- <1.0 mg/dl)
4. SGPT (ALT)- 26 U/L                            ( normal range- <34 U/L)
5. S . Alkaline Phosphatase- 54 U/L       ( normal range- 42- 98 U/L)
6. S. Lipase- 42 U/L                               ( normal range- <60 U/L)
7. S. Amylase- 82 U/L                           ( normal range- 25- 115 U/L)
8. RBS-   6.2 mmol/L                            ( normal range- Upto 7.8)
9. S. Creatinine- 0.97 mg/dl                ( normal range-  0.50- 1.1 mg/dl)
10. Urine R/M/E-
      Colour- Straw
      Appearance- Clear
      Epithelial cell- 0-2/HPF
      Pus cell- 0-2/ HPF
11. Plain X-RAY  Of Abdomen E/P : 
  No free gas is seen under  both dome of diaphragm. No abnormal
air fluid level is seen.
12. Chest X-Ray P/A: Normal
13. ECG: Within normal limit
CONFIRMATORY DIAGNOSIS:
         
Acute calculous cholecystitis

TREATMENT:
CONSERVATIVE MANAGEMENT:
1. NPO,
2. Fluid, Click to add text

3. Antibiotics,
4. Antiemetics,
5. Analgesic,
6. Antiulcerant

DEFINITIVE MANAGEMENT:
Laparoscopic Cholecystectomy
 Post operative period:

• Her post operative period was uneventful and stiches

were removed on 7th post operative day .
• Wound was healthy.
• Histopathology: Acute inflammatory cells were found in
mucosal layer, Myofibroblast, lymphocyte, plasma cell,
eosinophil and pigment laden macrophage was found.
Erosion of mucosa.
Findings: Acute Calculous Cholecystitis