Surgery Case Presentation

MACANAYA - MANGURIT - MELAD

GENERAL DATA
PATIENT: PL
● 66|MALE
● RIZAL, KALINGA,CAGAYAN
● MARRIED
● FILIPINO
● ROMAN CATHOLIC
● FARMER
● Birthday: JUN. 30, 1958
● Date of Admission: Aug. 20, 2024
● Time: 7:30 PM
● Type of Admission: Old
● Informant: Patient
CHIEF COMPLAINT

EPIGASTRIC PAIN
HISTORY OF PRESENT ILLNESS
5 days PTA
(-)fever
(+)epigastric pain radiating to
the RLQ and LLQ (-)chills

● pain worsened by food (-)dysuria

● No medications (-)nausea
● no consultations
(-)vomiting
(-)chest pain
(-)difficulty breathing
(-)back pain
HISTORY OF PRESENT ILLNESS
4 days PTA
- Sudden, intense, and sharp epigastric pain
- Radiation to chest, RLQ, and LLQ
- Scale of 10/10
- Consulted at Juan M. Duyan Memorial District
Hospital, Rizal, Kalinga
- Patient was admitted.
- Platelet count=91.
- Dengue NS1 +
- IgG test +
- Initially diagnosed with dengue.
HISTORY OF PRESENT ILLNESS
1 day PTA
(+) upper back pain
(+)abdominal distention
- Aggravated by supine and standing position
- Alleviated by left or right lateral decubitus positions
- Abdominal ultrasound=cholecystolithiasis and splenomegaly
- Referred to CVMC
- Admitted
PAST MEDICAL HISTORY

Medications None
Immunization BCG, others unrecalled
Childhood illness Chicken pox, measles
Allergies No known allergies
PAST MEDICAL HISTORY

Adult illness Mild stroke, 2013

Surgical procedures Boil Excision, unrecalled date
Previous Hospitalizations July 2024, Leptospirosis and
typhoid fever at Juan M. Duyan
Memorial District Hospital
Screening Tests Urinalysis, X-ray
Family History
Paternal Side Maternal Side Relationship to the px

Cancer (+) (-) Father

Hypertension (-) (+) Mother

Diabetes (-) (-)

Tuberculosis (-) (-)

Heart Disease (-) (-)

Stroke (-) (+) Mother

Kidney Disease (-) (-)

PERSONAL AND SOCIAL HISTORY

No. of years married 40

No. of Children: 4
Health Status of Children No diseases recorded to date
Occupation Farming
PERSONAL AND SOCIAL HISTORY
Nutrition

No. of meals per day 3

Food preferences Vegetables, meat, and fish, but
he also consumes dinakdakan
and other greasy foods as
pulutan.
Coffee/tea/soda intake takes 1 cup black coffee daily,
occasionally drinks soft drinks
Nutrient Supplement None
PERSONAL AND SOCIAL HISTORY
Nutrition

Smoking Habits 10 sticks per day. Started at 15

y/o. Quitted July 2024 (51 years
of smoking)

25.5 pack years

Alcohol Consumption 1 bottle (350ml) of gin
occasionally
Prohibited Drugs None
Substance Abuse None
PERSONAL AND SOCIAL HISTORY
Living Conditions

No. of years in current 56

residence
Previous place of residence 10 years at Cataggaman
Type of residence Owned, bungalow with 3 rooms
No. of occupants 6
Relationship to occupants Spouse, daughter, son-in-law
and 2 grandchildren
PERSONAL AND SOCIAL HISTORY
Source of Drinking Water Purified
Garbage Disposal Compost pit, unsegregated
Fecal Disposal Owns a toilet
Pets Dog
REVIEW OF SYSTEMS
Constitutional (-) fever, (-) chills, (-) fatigue, (-) altered mental status, (+)
weight loss

Skin (-) rashes, (-) itching, (-) dryness, (-) pigmentation changes, (-)
bleeding,

HEENT (-) headache, (-) trauma, (-) pain, (-) redness, (-) Lacrimation,
(+) Blurred vision, (-) earache, (-) epistaxis, (-) Itching, (-)
Nasal Stuffiness, (-) bleeding gums, (-) toothache, (-) mouth
sores, (-) Dental caries, (-) oral thrush

Respiratory (-) cough, (-) wheezing,(-) sputum

Cardiovascular (+) chest pain, (-) orthopnea, (-) edema, (+) easy
fatigability, (-) Paroxysmal Nocturnal Dyspnea, (-)
Palpitations
REVIEW OF SYSTEMS
Gastrointestinal (+) Loss of appetite, (-) Nausea, (-) vomiting, (-)
Hematemesis, (-) Hematochezia, (+) Abdominal pain, (-)
Diarrhea, (-) Excessive Belching/Passing of gas

Renal (-) Dysuria, (-) Polyuria, (-) Nocturia, (-) Gross Hematuria, (-)
Incontinence, (-) Urinary Retention, (-) Urinary Urgency, (-)
Tea colored urine

Muskuloskeletal (-) Muscle weakness, (-) Joint swelling, (-) Stiffness, (-) Muscle
pain, (-) Joint pain, (+) Backache

Neurologic (-) Paralysis, (-) Seizures, (-) Numbness, (-) Tremors, (-)
Memory loss

Hematologic (-) Easy bruising, (-) Bleeding, (-) Pallor

REVIEW OF SYSTEMS
Endocrine (-) Polydipsia, (-)polyphagia, (-) Heat/cold intolerance, (-)
excessive sweating

Psychiatric (-)Nervousness, (-) Depression, (-) Anxiety, (-) Hallucinations

PHYSICAL EXAMINATION
VITAL SIGNS
GENERAL SURVEY
Temperature: 37°C (axillary)
Patient is cooperative, RR: 20 cpm
coherent and in a Pulse: 86 bpm
pleasant mood, but BP: 110/80 mmHg
showing sign of 02% Sat.: 97% room air
distress. Height: 5 ft 5 inches
Weight: 57 kgs.
BMI: 20.95kg/m2(Normal)
PHYSICAL EXAMINATION
Integumentary (-) Bruises (-) Petechiae, (-) jaundice, (-) Pallor, (-)
cyanosis, (-) pigmentation, (+) warm to touch and taut
on the abdomen (RUQ)

Head Normocephalic, atraumatic, no facial asymmetry,

(-)masses, (-)tenderness (-) tenderness

Eyes (-) (cornea /sclera) discharge,(-)periorbital edema,

HEENT (+)pale conjunctiva; (-) icteric sclera; Eyeballs are
symmetrical in size and position; Pupils are equal, round
and reactive to light and accommodation.
Physical Exam
Ears (-) swelling, (-) redness, (-)discharge, nontender, (-)
excessive cerumen

Nose symmetrical , non tender sinuses, (-) obstruction, (-)

congestion, (-) lesion, (-) exudates,(-) alar flaring; nasal
septum is midline, intact with no perforations

HEENT Mouth and Lips is dry, discolored, without lesions; Teeth is complete;
Throat Gums and mucous membranes are pale and moist, without
bleeding, lesion or inflammation; Tongue normal in size and
papillation; Tonsils not enlarged,

Neck Supple with full range of motion (ROM); (-) masses, (-)
tenderness; Thyroid gland not palpable.
Physical Exam
Chest and Lungs Respiratory excursion full and symmetrical; Clear to auscultation and
percussion; no rales, ronchi, wheezes or rubs; vocal and tactile fremitus
normal

Heart No abnormal heaves or lifts. Regular rate and rhythm; No extra sounds or
murmurs.

Gastrointestinal (+)Distended abdomen, (+) tenderness, (+)rigidity (+) guarding (+)

shifting dullness

Extremities No asymmetry or muscle atrophy. Full range of motion (ROM) of all joints.
Normal skin temperature ; (-) edema, (-) tenderness, (-) redness; all distal
pulses are intact and equal;
Physical Exam

Abdominal
Measurement
Physical Exam
Genitalia Grossly male

Neurologic Awake, alert and oriented; memory is normal and thought process is intact

Cranial Nerves Intact, normal motor function, intact sensation bilaterally

ADMITTING DIAGNOSIS
Cholecystolithiasis w/ Dengue
SALIENT FEATURES
● 66 y/o ● Loss of Appetite
● Male ● Distended Abdomen
● Epigastric pain ● Abdominal Tenderness
● Farmer ● Backache
● Alcohol Drinker ● Abdominal Guarding
● Eats greasy food as ● Unintentional Weight loss
pulutan
DIFFERENTIAL DIAGNOSIS
Rule In Rule Out

ASCENDING Alcohol Drinker Fever

CHOLANGITIS Eats greasy food as pulutan Jaundice
Epigastric/RUQ pain Altered Mental Status
Distended abdomen To confirm
Abdominal Guarding CBC-PC
Fatigue Liver function test
Abdominal Ultrasound
ERCP

CHOLEDOCHOLITHIASIS Alcohol Drinker Fever

Eats greasy food as pulutan Jaundice
Unintentional Weight loss Pruritus
Epigastric pain To confirm
Abdominal Guarding Abdominal Ultrasound
MRCP/ERCP
Endoscopic UTZ
DIFFERENTIAL DIAGNOSIS
Rule In Rule Out

LIVER ABSCESS Unintentional weight loss Fever

Epigastric /RUQ pain Chills
Distended abdomen Night sweats
Abdominal Guarding Subcostal tenderness
Right shoulder pain (referred
pain)
To confirm
CBC-PC
Chest Radiograph

GALLSTONE Epigastric Nausea

PANCREATITIS Abdominal Guarding Vomiting
Distended Abdomen To confirm
Abdominal Tenderness Lipase and Amylase Test
Backache Abdominal Ultrasound
Fatigue CT Scan
MRCP
WORKING DIAGNOSIS
CHOLECYSTOLITHIASIS
CASE DISCUSSION
CASE DISCUSSION
CASE DISCUSSION
Gallstones
Classified into two major subtypes:
Cholesterol Stones
- usually multiple, of variable size, and may be hard and faceted or
irregular, multilobed, and soft
- multilobed, and soft
- (>90%) are radiolucent, though some have a high calcium carbonate
component and become radiopaque.
- Colors range from whitish yellow to green or black.
- Pure stones are uncommon and account for <10% of all stones
- usually occur as a single large stone with a smooth surface
- Majority are mixed but are at least 70% cholesterol by weight in addition
to variable amounts of bile pigments and calcium.
CASE DISCUSSION
Pigmented Stones
- contain <20% cholesterol and are dark because of the presence of calcium bilirubinate.
- Black Pigmented Stones
- are usually small, brittle, dark, and sometimes spiculated
- formed by supersaturation of unconjugated bilirubin within the bile.
- Asian countries such as Japan, black stones account for a much higher percentage than in
Western Hemisphere
- Brown Pigmented Stones
- usually <1 cm in diameter, brownish-yellow, soft, and often mushy
- form either in the gallbladder or in the bile ducts secondary to bacterial infection and bile
stasis.
- Bacteria such as Escherichia coli secrete β-glucuronidase that enzymatically cleaves
conjugated bilirubin to produce the insoluble unconjugated bilirubin.
- unconjugated bilirubin then precipitates with calcium, and along with dead bacterial cell
bodies, forms soft brown stones in the biliary tree
- Brown stones
- are typically found in Asian populations and are associated with
- stasis secondary to parasite infection with Ascaris lumbricoides(roundworm) or
Clonorchis sinensis (liver fluke)
DIAGNOSTIC TESTS
● Blood Tests
○ CBC (Complete Blood Count), ALT (Alanine Transaminase), AST (Aspartate Amino
Tranferase), Total Bilirubin, Alkaline Phosphatase, Amylase and Lipase Level
● Transabdominal Ultrasonography
○ Show stones in the gallbladder with sensitivity and specificity of >90%.
● Endoscopic retrograde cholangiopancreatography (ERCP)
○ diagnostic and potential treatment procedure involving the insertion of a long, thin,
and flexible tube with a camera attached (i.e., an endoscope) through the mouth,
down toward the small intestine.
TREATMENT
TREATMENT
Percutaneous Transhepatic Cholecystostomy
Tubes
TREATMENT
Endoscopic Retrograde Cholangiopancreatography
(ERCP)
TREATMENT
Cholecystectomy
TREATMENT
Cholecystectomy
Laparoscopic cholecystectomy
the approach of choice for most patients.
Advantage:
Less morbidity, shorter length of hospital stay, lower cost, and faster recovery to
normal function

In patients with biliary colic, although with more difficult

target anatomy due to acute inflammation; the addition of more trocars or other
techniques for improving visualization may be needed.
TREATMENT
Cholecystectomy
Open cholecystectomy
Several risk factors requiring conversion to open cholecystectomy including
prior upper abdominal surgery, obesity, long duration of symptoms and
cirrhosis
TREATMENT
DISSOLUTION THERAPY
Asymptomatic No medical therapy aside from pain control is recommended
pigmented or calcified
gallstones

Symptomatic patients Oral ursodeoxycholic acid (ursodiol [Actigall]) and chenodeoxycholic acid
who are not candidates ( 6 to 12 months of therapy)
for surgery or those
Extracorporeal shockwave lithotripsy
who have small
gallstones (5 mm or
smaller) in a functioning
gallbladder with a
patent cystic duct
TREATMENT
TREATMENT
PAIN CONTROL

● NSAIDS (e.g. KETOROLAC)

● MEPERIDINE
● ANTISPASMODIC (e. g. SCOPOLAMINE)
○ which are thought to relax and relieve the spasms of the
gallbladder.
MANAGEMENT
● Conservative Management (Asymptomatic)
● Regular follow-ups without surgery
● Lifestyle modifications
● Complicated Cases
● Acute Cholecystitis: This is treated initially with antibiotics and fluids, followed by early
cholecystectomy within 72 hours for most patients.
● Choledocholithiasis: This is managed with a combination of ERCP (endoscopic removal of
bile duct stones) followed by laparoscopic cholecystectomy to prevent recurrence of stones.
● Prevention and Long-term Care:
○ Lifestyle modification, including weight management and a low-fat diet, is often recommended
to prevent further stone formation, especially in patients at high risk of gallstone recurrence
Patient Update
● Patient is still under monitoring because of his thrombocytopenia secondary to Dengue
● The patient undergone another set of laboratory tests
○ CBC ( thrombocytopenia)
○ Fecalysis (+ occult blood)
○ Prothrombin Time (prolonged)
○ Viral Hepatitis Panel (non reactive)