Post op case Presentation

Hamil Romulo B. Guerrero, MD

Surgery Resident
 OBJECTIVEs

• To present a case of a 7/F who underwent

exploratory laparotomy, cholecystectomy,
appendectomy for hydrops of the gallbladder

• To discuss hydrops of the gallbladder in children

 IDENTIFYING DATA
• H.J
• 7 years old
• Female
• Filipino
• Islam
• Marantao, Lanao del Sur
• Admitted February 5, 2018
 CHIEF COMPLAINT
• Abdominal pain
HISTORY OF PRESENT ILLNESS
(+) Fever
10 days PTA - (-) cough and colds
(-) dysuria

3 days PTA - (+) Fever

(+) epigastric
pain
Day of admission– (+) Nausea

(+) Fever
(+) Abdominal
Pain, RHA
(+) Nausea
and Vomiting
 PAST/FAMILY MEDICAL HISTORY
• No allergies
• No surgeries
• No hypertension
• No diabetes mellitus
• No asthma
• No heredofamilial diseases
 PERSONAL AND SOCIAL HISTORY
• Grade I elementary student
• non-smoker
• non-alcoholic beverage drinker
• Regular child diet
 REVIEW OF SYSTEMS
: no weight loss
: no fever
GENERAL : no anorexia
: no easy fatigability

: no bruising
SKIN : no rashes
: no lumps

: no head injury, no trauma

: no ear discharges
HEENT : no nasal discharges, no epistaxis
: no mouth sores
: no mass
 REVIEW OF SYSTEMS
: no changes in attention, speech
: no changes in orientation, memory, insight
and judgement
NEUROLOGIC : no loss of consciousness
: no seizures, paralysis
: no numbness or loss of sensation, tingling,
tremors

: no colds
RESPIRATORY : no hemoptysis
: no dyspnea

: no cyanosis
CARDIOVASC : no chest pain
ULAR : no palpitations
 REVIEW OF SYSTEMS

GASTROINTEST:: no black tarry stools

no rectal bleeding, constipation, diarrhea
INAL : no belching or passing of gas

MUSCULOSKEL : no loss of muscle mass

ETAL

GENITOURINA : : no dysuria
RY : : no incontinence
PHYSICAL EXAMINATION

GENERAL : Conscious, Coherent, Ambulatory, Not in

SURVEY respiratory distress, Pain score 8/10

BP : 110/80 mmHg
HR : 127 bpm
RR : 21 cpm
VITAL SIGNS Temp : 38.5 'C
O2 Sat : 98%
Wt :20 kg
SKIN
 HEENT
• (+) soft tissue contusion at the Left fronto-
temporal area, (-) Pallor
• (-) hematoma, ecchymosis, neck tenderness
 HEART

• Regular rate and rhythm

• (-) muffled sound
 CHEST AND LUNGS
• (-) abrasions, hematoma contusion,
deformities, equal chest expansion,
tachypneic at 26cpm
• Clear breath sounds
 ABDOMEN
• flat, no hematoma, no scars, (+) tenderness on
deep palpation right iliac area, normoactive
bowel sounds,
 Extremities
• no deformities, no abrasions, equally palpable
pulses
 IMPRESSION

ACUTE ABDOMEN SEC TO RUPTURED

APPENDICITIS
 CBC

Hemoglobin 12.20
Hematocrit 0.36
RBC count 4.50
WBC Count 9.90
Neutrophils 0.76
Lymphocytes 0.15
Monocytes 0.08
Eosinophils 0.01
Platelets 320
 CBC

Hemoglobin 10.00
Hematocrit 0.31
RBC count 3.82
WBC Count 5.90
Neutrophils 0.67
Lymphocytes 0.27
Monocytes 0.06
Eosinophils 0
Platelets 320
 BLOOD CHEMISTRY

SODIUM 138.36
POTASSIUM 4.21
SGOT 38.7
SGPT 4.21
BUN 23.65
CREA 0.76
ALP 386
 IMMUNOLOGY
• IgG, IgM for typhoid fever
– IgG POSITIVE
– IgM POSITIVE
 Referred to SURGERY
• Assessment: Acute abdomen sec to ruptured
appendicitis
 SURGERY
• Exploratory laparotomy, cholecystecomy,
appendectomy
 1 POD
st

S/O: (+)post op pain • Plan: Kink NGT, General

(+)Flatus (-)BM liquids
– (+) flat, intact post op site -px may turn –to-
– (+) soft, nontender sides and may sit up on
bed
-Change dressing
• Ass: S/P Exlap, done
cholecystectomy,
appendectomy
 2 POD
ND

S/O: (+)post op pain (+)Flatus • Plan: Progressive diet

(+)BM (+) tolerated general -px encourage
liquids
– (+) flat, intact post op site
ambulation
– (+) soft, nontender -Change dressing
done

• Ass: S/P Exlap,

cholecystectomy,
appendectomy
 3 POD
RD

S/O: (+)post op pain (+)Flatus • Plan: MGH

(+)BM (+) tolerated
progressive diet
– (+) flat, intact post op site
– (+) soft, nontender

• Ass: S/P Exlap,

cholecystectomy,
appendectomy