Date and Time of Interview: November 23,2021 3:15PM

General Data: JDG, 45/F, residing in Navotas, married, Roman Catholic

Chief Complaint: abdominal pain

History of Present Illness:

2 days prior to consult, the patient experienced constipation.

Six hours prior to consultation, the patient started to experience persistent abdominal pain located initially
at the right side then to the epigastric area. The pain is increasing in severity with pain scale of 10/10. The
patient cannot recall what can aggravate the pain and takes mefenamic acid 500mg once a while ago.
The patient also experienced fever of 38oC, fatigue, vomiting and loss of appetite.

Past Medical History:

Patient has hypertension and non-compliant to medication
Patient has high cholesterol noted by her doctor
No childhood illnesses
No hospitalizations
No allergies

Personal and Social History:

 Stopped smoking 20 years ago.
 Works as a cook in a carinderia,
 Lives with her husband and children in a house near the road
 Eats small portion of food mostly eats fish, vegetables and meat
 No illegal drugs

OB/Gyne History:
Last pregnancy was at age 40 years old
Regular menstruation with duration of 3 days

Family History:
Mother: Age is 50 years old with complication of diabetes, deceased

Father: Cannot recall age with complication of hypertension, deceased

Review of Systems:
General: (+) weight loss, (+) fatigue, (-) changes in hair or nails, (-) excessive sweating
Skin: (-) rashes, (-) redness, (-) skin lesions, (-) changes in color
HEENT: (+) dizziness, (-) headache, (-) blurring of vision, (-) dimming of vision, (-) epistaxis, (-) tinnitus, (-)
loss of hearing, (-) bleeding of gums (-) sore throat, (-) neck stiffness
Respiratory: (-) cough, (-) dyspnea, (-) wheezing, (-) no hemoptysis
Cardiovascular: (+) occasional chest pain, (-) orthopnea, (+) palpitations, (-) edema
Genitourinary: (-) dysuria, (-) changes in urine character or amount, (-) changes in menstrual flow, (-)
vaginal discharge, (-) hematuria
Musculoskeletal: (-) joint pain or swelling
Endocrine: (-) heat/cold intolerance, (-) polyuria, polydipsia, polyphagia

PHYSICAL EXAMINATION
Conscious, coherent, oriented, lying supine
BP=160/100, HR=110/min, RR=24/min T=38.4C
Pink palpebral conjunctivae, (+) icteric sclerae, (-) cervical lymphadenopathy, (-) bruits, (-) anterior neck
mass, (-) neck vein distention
Equal chest expansion, no retractions, clear breath sounds
(-) heaves/thrills, AB at 5th LICS MCL, good S1, (-) S3/murmurs
soft abdomen, Normoactive Bowel Sound (NABS), (+) direct RUQ tenderness, (-) rebound tenderness,
liver and spleen not palpable
(-) edema, full pulses

INTERPRETATIVE SUMMARY.
Our patient is a 45/F who presented complaining of acute onset of abdominal pain from the right to the
epigastric area with increasing severity and pain scale of 10/10, takes mefenamic acid of 500mg for relief
and not aggravated by food or allergies. The abdominal pain occurred six hours prior to consult with
accompanying fever of 38oC, one episode of non-bloody vomiting, fatigue, and loss of appetite. She is
also hypertensive with medication and hyperlipidemia without medication. The patient’s eating habits
consist of tasting food from cooking mostly fish, vegetables, and meat. The patient is also smoker but
stopped 20 years ago, no hospitalizations, no exposure to communicable diseases. Her menstruation
cycle is regular, and her last pregnancy was when she was 40 years old. Her physical exam shows that
she is hypertensive, tachypneic, fever, has icteric sclerae and direct right upper quadrant tenderness.

DIAGNOSIS
Primary Working Impression: Ascending cholangitis
Differentials: Acute Cholecystitis
Choledocholithiasis
Acute Pancreatitis

Secondary Diagnosis/Co-morbidities: Stage II Hypertension

DISCUSSION
A 45/F patient presented with signs and symptoms of acute abdominal six hours prior to
consultation from the right side of the abdomen to the epigastric area with signs of icteric sclerae, fever
and biliary colic pain, she also vomits. It is Acute cholangitis as my primary working impression because
of the criteria of Charcot’s triad which are biliary colic pain, jaundice and fever. This is a systemic infection
of the bile ducts due to bacteria caused by complications from biliary obstruction, infection of bile and
elevation of intraluminal pressure. For biliary obstruction the causes are gallstones, malignancy, benign
stricture and parasites. From the patient’s history, she mentioned to have hypertension and
hyperlipidemia in which the latter is a risk factor for gallstone formation. Her hyperlipidemia possibly is
due to high cholesterol diet from cooking and tasting food. Her physical findings of fever, hypertension,
icteric sclerae, Stage II hypertension, and has direct right upper quadrant tenderness correlates to the
clinical manifestation of ascending cholangitis.

One, differential diagnosis which is acute cholecystitis, it is the inflammation of the gallbladder
due to obstruction of the gallstone in the cystic duct. This is considered because of the patient’s risk
factors and clinical manifestations of fever, right upper quadrant pain, hyperlipidemia, and vomiting.
However, this disease does not have a manifestation of jaundice which is present in the patient, icteric
sclerae.

For choledocholithiasis it has the same cause which is obstruction due to gallstone however this
blocks the common bile duct. Its signs and symptoms are right upper quadrant pain, jaundice and
vomiting. However, this is ruled out because the patient presented with fever that might indicate infection
and the patient has tachycardia and tachypnea.

The last differential diagnosis that I considered is Acute Pancreatitis because of similar
presentation to ascending cholangitis such as RUQ abdominal pain, fever, vomiting, and jaundice.
However, its s ruled out due to no presence of pain radiating to the back, Cullen’s sign and Grey Turner
sign.

PROBLEM LIST and MANAGEMENT PLAN

1) Abdominal pain, icteric sclerae

 Diagnostics:
Abdominal CT scan or ultrasound- determine presence of gallstone, malignancy, organ
enlargement

CBC- to look for signs of leukocytosis

Endoscopic Retrograde Cholangiopancreatography- can be used as a diagnostic and therapy for

gallbladder or pancreatic problems.

Endoscopic Ultrasound- to rule out choledocholithiasis

Serum amylase and lipase, C-reactive protein- rule out acute pancreatitis

Liver function test (AST and ALT)- to assess function of the liver

Therapeutics:
IV Antibiotics: if infection is confirmed to remove bacterial infection and avoid any post-operative
complications

ERCP: to remove gallstones which is necessary for treatment

2) Hypertension and Hyperlipidemia

Diagnostics:
Sphygmomanometer- check blood pressure regularly

Lipid profile- to determine cholesterol levels

Serum creatinine- to check for kidney function

Electrocardiogram- to check the electrical activity of the heart

Treatment:
Pharmacologic: Encourage the patient to continue amlodipine as her maintenance drugs, advise
to take ACE inhibitors, ARBs, Thiazides, or calcium channel blocker depending on the blood pressure and
ECG of the patient

Non-pharmacologic: Advise patient to avoid fatty foods and eat more fruits and vegetables,
exercise regularly,

3) Constipation
Diagnostics:
Sigmoidoscopy- check the rectum and lower portion of the colon for any obstruction or
inflammation

CBC- check for leukocytosis

Barium enema- to look for any obstruction present

Treatment:

Pharmacologic: Laxatives, Lactulose, Docusate, Bisacodyl

Non-Pharmacologic: Increase fiber intake, encourage to eat more fruits and vegetables
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PERSONAL REFLECTIONS: Please include this reflection in your written report.

1) Please rank the following components for this activity from 1-5 (with 1 being the easiest, 5
hardest):
5-bedside history-taking and physical exam
3-discussion of differential diagnosis
2-generating problem list and plan
4-organizing case presentation
1-organizing written report

2) What made your #1 activity easy? What made your #5 activity difficult?
- Organizing the written report was at least a bit easy for me because I was able to check my
grammar and how to type it in the report. I had a very hard time in history-taking and physical
exam because I wasn’t able to get the information that I wanted from the patient and had difficulty
in asking the question in Filipino.

3) What improvements can you make for your performance in the next activity?
- I would have to watch on how doctors ask questions to their patients and listen to the lectures
on how to ask question on different organ systems.