Case Report, General Surgery

4/9/2023
Morning Report
Present by
Amlak Salman Almatrafi Norah Sattam Alruwili
Asayel Mojida Alshamari Rawand Ali Alruwili
May Hamad Alqaed Reham Thani Alruwili
Overview
1 History 4 Investigation
2 Examination 5 Treatment
3 Diagnosis 6 Discharge plan
Case scenario
A 45-year-old Saudi female teacher presented to OPC 3 weeks ago

complaining of right abdominal pain that radiates to the back and
between the shoulders.
History
Personal Data
Patient Name: TURKIAH ZUWAYYID NAFEL ALSHARARI

Age: 45 y
Nationality: Saudi
Marital state: Married (2 Children)
Residency: Abo-Agrm | sakaka
Occupation: Teacher
Date of admission: 29/8/2023
Chief Complaint
Right abdominal pain.

History of Presenting Illness
The patient was complaining of right upper quadrant pain that

started 3 weeks ago after eating a fat rich meal, the pain was
sever and intermittent for 3 days, then it became less severe.
The pain radiate to the back and between the shoulders. The pain
was 8/10 in severity, aggravated by eating a fatty meal which
lasted for several hours and relived by analgesics.
Past medical history
Known irritable bowel disease and Polycystic ovary syndrome
(PCOS)
No blood transfusion.
No allergy
Past drug history

Metformin for Polycystic ovary syndrome
Dose: 50 mg.
Frequency: twice daily for 3 months.
Paracetamol for Irritable bowel disease
Dose: 500 mg.
Frequency: with pain.
Past surgical history
2 cesarean section with general anesthesia.
Family history
No family history of chronic disease.

No family history of Similar condition.
Reproductive health
The Age of menarche is 15 y
Irregular cycle.
Does not take any contraceptive methods.
Social history
Non smoker no alcohol intake.
Minimal physical exercise on weakly basis.
Live with her family (husband and 2kids).
Middle socioeconomic status.
Travel history
went to Jordan 4 years ago.

Systemic Review
No fever No palpitation There is no change in The patient has Chest pain

No change in the weight No orthopnoea the color, amount and No dyspnoea
No paroxysmal frequency of the urine No cough and sputum
nocturnal dyspnea No dysuria No haemoptysis
No ankle swelling No polyuria
No hematuria
No vaginal discharge
Systemic Review
The patient has right upper The patient has headache No skin changes, rash,
quadrant pain and anorexia No loss of consciousness itching.
No jaundice No visual and hearing problem There is no history of
No nausea and vomiting No numbness joint, muscle and bone
No heart burn No tremor pain
No dysphagia No psychiatric disorders No movement difficulties
No diarrhea
No constipation
Examination
General examination
She looked well, conscious, oriented to time, place and person.
There is no sign of distress.
She was not pale, jaundice or cyanosed.
BMI:27.35 kg/m2
The hands were warm with no pallor or palmar erythema,

No finger clubbing or flapping tremors.
General examination
The eyes showed no jaundice or pallor.
Good oral hygiene, no central cyanosis or ulcer.
The neck showed no palpable lymph nodes or thyroid enlargement.
The chest showed no dilated veins or any others deformity.
No lower limbs edema.

Vital signs
BP : 124/68 mmHg
Temperature : 36.9 C
Pulse rate : 88/ min
Respiratory rate : 20/ min
Examination
Inspection:
-The abdomen was :

flat, symmetrical, Freely mobile
-The skin overlaying the abdomin :

Normal color
Pfannenstiel incision
No pigmentation
No sinuses or fistulas
No dilated veins
Examination
Inspection:
-Umbilicus is central and inverted
-No visible pulsation nor peristaltic movement
-Intact hernial orifices and no couph impulse

Examination
Palpitation:
Superficial palpation :
-Normal temperature
-No rigidity nor superficial mass
-Slight tenderness over the right upper quadrant
Deep palpation :
-The liver , spleen and kidney not palpable.
-No palpable mass
-No rebound tenderness
-Negative Murphy's sign
Examination
Percussion:
-Resonance over bowals and trub's area

-Negative shifting dullness
Auscultation:
-Bowel sounds were audible (Gurgling bubbling) and normal

-No aortic bruit
-No hepatic nor splenic friction rub.
-No venous hum
Discussion
Management
Investigation - Treatment
Lab results
Preoperative tests:
CBC
Lab results
Preoperative tests:
LFT
Coagulation profile
Lab results
Preoperative tests:
KFT
Radio results
Preoperative tests:
Abdominal US
Diagnosis
Cholelithiasis
Management
Investigation - Treatment
Treatment plan (Preoperative )
Medical treatment:
Analgesics including paracetamol and ibuprofen to control the pain/biliary colic,

The patient was advised to follow a low-fat diet.
Surgical treatment:
The patient had a selective laparoscopic cholecystectomy.
Pre-operative care included:

( NPO- IV fluid D51/2NS 120cc/h - antibiotic IV “cefazolin” on
call to OR).
The procedure was performed, patient tolerated it and

was shifted to recovery.
*D5 1⁄2 NS
Post-operative care:
Vital signs observation_O2 nasal prongs_NPO_ 120ml D51/2NS
IV fluids, the dressing was clean and there was no bleeding_
pneumatic compression while on bed.
Patient sipped water after 6h and gradually proceeded to a

fat-free liquid and soft fat-free diet as tolerated_started
ambulation after 6h as tolerated.
Medication:
Cefuroxime 1.5gm IV TID Omeprazole 40 gm OD
Paracetamol 1gm IV TID Enoxaparin 40 gm SC OD
*TID 3 times a day- OD once daily
Discharge
plan
Discharge plan:
The patient was discharged on the second-day post operation,

and asked to follow a 2-week fat-free diet.
Summary
45 year old female was complaining of right upper quadrant pain

that started 3 weeks ago after eating a fat-rich meal, The pain was
severe and intermittent for 3 days, then the pain became less
severe, the pain radiated to the back and between the shoulders.
Ultrasound revealed a 2cm gallstone within the gallbladder where

the patient had a selective laparoscopic cholecystectomy.
Thank you

Case Report, General Surgery

Uploaded by

Copyright:

Available Formats

Case Report, General Surgery

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case Report, General Surgery

Uploaded by

Copyright:

Available Formats

4/9/2023

A 45-year-old Saudi female teacher presented to OPC 3 weeks ago

Patient Name: TURKIAH ZUWAYYID NAFEL ALSHARARI

Right abdominal pain.

The patient was complaining of right upper quadrant pain that

Past drug history

2 cesarean section with general anesthesia.

No family history of chronic disease.

went to Jordan 4 years ago.

No fever No palpitation There is no change in The patient has Chest pain

There is no sign of distress.

She was not pale, jaundice or cyanosed.

The hands were warm with no pallor or palmar erythema,

The eyes showed no jaundice or pallor.

Good oral hygiene, no central cyanosis or ulcer.

The neck showed no palpable lymph nodes or thyroid enlargement.

The chest showed no dilated veins or any others deformity.

No lower limbs edema.

-The abdomen was :

-The skin overlaying the abdomin :

-Umbilicus is central and inverted

-No visible pulsation nor peristaltic movement

-Intact hernial orifices and no couph impulse

-Resonance over bowals and trub's area

-Bowel sounds were audible (Gurgling bubbling) and normal

Analgesics including paracetamol and ibuprofen to control the pain/biliary colic,

The patient had a selective laparoscopic cholecystectomy.

Pre-operative care included:

The procedure was performed, patient tolerated it and

Patient sipped water after 6h and gradually proceeded to a

The patient was discharged on the second-day post operation,

45 year old female was complaining of right upper quadrant pain

Ultrasound revealed a 2cm gallstone within the gallbladder where

You might also like