Arrive at 0700 6/6

5mm (normal <3mm) Thickened gallbladder wall

Walk in with stretcher
Murphy’s sign positive Evidence
Admission Emergency admission
10mm (normal <6mm)
Bile duct dilated Acute Cholecystisis with Obstructive Temperature: 38.5°C
Choledocholithiasis
Diagnosis
8mm gallstone obstruction
Pulse: ~105bpm
No evidence of perforation, abcess or Vital signs
pancreatisis Blood pressure: 140/90

Respiration rate: 18/minute

Temperature

Pulse Fever 38.5 C

Vitals Q4H
Sever RUQ abdominal pain chained to right Pain increased after meal, over the counter pain
Blood pressure
shoulder med didn’t work
Respiration rate
Nausea

WBC Main complaint (+S/S) Vomiting Greenish vomit 100ml Bile reflux Symptoms lasts for 1 day
↑
Complete Blood Count
Ongoing infections or inflammations Excessive bile excreted via kidney + lack of bile
ESR↑ Dark urine + Pale stool
in stool caused discoloration

Neutrophils ↑ Differential Count Jaundice Bilirubin accumulation

Possible Liver disease/bile duct obstruction/ Insomnia

excessive RBC breakdown
Total bilirubin (direct + indirect bilirubin)↑
Ms. Suen
Liver disease/bile duct obsruction Direct bilirubin ↑
Blood (Need more info) F/58
Liver inflammation/infecton caused by
Liver damage ALT↑ Liver and Renal Function Test BMI 33
cholecystisis

Liver damage/inflammation/bile duct Lives with family

ALP↑
obstruction
Secondary education
Infections/inflammation C-reactive protein↑ Background
Waitress
No results yet Type and screening
Smoker drinker 1-2 packs per day/social drinker
Inject contrast for X-ray
Type 2 DM On Metformin
Biopsy
Endoscope Past medical history Hypertension On Losartsn
Brush cytology
Gallstone for 5 years Conservative treatment
Diagnostic
Cholangiopancreatoscopy

X-Ray
ERCP (pending) Being woman

Inflate balloon behind the stone and sweep Management

Gallstone removal More than 40 years old
stone out of bile duct
Therapeutic
Risk factors Has diabetes
Cutting and enlarging ampulla of vater Sphincterotomy
Has high blood cholesterol level
H’Stix Q4H
Pre-existing gall stones
Keep NPO

Treat hypertension
IV Losartan
Coadminister with drugs which increase serium
potassium (hyperkalemia)

NSAID (pain relief/reduce inflammation)

IMI Ketorolac
Renal damage (fluid retentions), GI bleeding,
Gastric damage

Preemptive antibiotic treatment before surgery Intra-abdominal infections

IV Tazocin (Penecillin)
Allergy
Medications
Treat short term acid reflux
IV Pantoloc
Allergy

Treat nausea and vomitting

IV Maxolon
History of stomach bleeding/injury, bradycardia,
adrenal gland tumour, seizures

Reduce blood sugar level

Metformin withdrawn
Recent or ongoing heart failure

IV 50/50 500ml Q6H