Case
cholelithiasis

Age: 31
Sex: Female
Race: Filipino

History
History of present illness:
Five months prior to admission, the patient complained of right upper quadrant pain radiating to the epigastric area. Two months prior to admission the client seek for medical attention upon consultation she was advice for a surgery. Two weeks prior to admission client experience intense right upper quadrant pain with feeling of bloated ness accompanied by nausea and vomiting.

Medical History:
Upon patientís interview, she told that this was the first time to be admitted at the hospital and undergone surgery. But the patient verbalized that she experiences cough and colds or fever at least once a year.

Family history:
Mother: Heart disease
Father: heart disease



Physical Exam
General:
Lying flat on bed
Conscious and coherent
Irritable
Time and pale oriented


Temperature:
36.5 Celsius

Heart rate:
81 beats/min

Blood pressure:
130/900 mmHg

Respiratory rate:
18 cycle/min

Head, ears, eyes, nose & throat:
Head Normocephalic
Scalp is moist
No masses or lesion noted

Eyes Bulbar conjunctiva is transparent with some capillaries evident
Sclera is white in color
Pink conjunctiva
No alteration in sight

Ears Pinna are symmetrical, mobile, firm and non-tender
External ear canal has no lesion
Serum noted
No alteration in hearing

Nose Symmetrical and straight
No noted flaring of nares
No noted tenderness and lesions

Throat and oral Lips are not pale but dry and cracked
Teeth are whitish
Gums are pink, no bleeding noted
With good swallowing and gag reflex
Fruity breath noted
Tongue is pink and moist, no lesion noted
High salt taste preference


Neck:
muscle are equal in size, head centered
no discomfort upon movement
lymph nodes not palpable


Chest:
shallow respiration due to pain (18 cycle/min)
unilateral chest expansion
no adventitious breath sound noted


Cardiovascular:
Apical and radial pulses are palpable
Bounding radial pulse
No murmur noted


Abdomen:
skin is pale
incision sight RUQ (10 cm)
flat with stretch marks
abdominal girth: 39 inches
symmetric movement during respiration
hypoactive bowel sound upon auscultation
dullness during percussion in spleen area
tenderness and pain (incision site) noted during palpitation


Neurological:
no defect in speech
time and place oriented
no lapses of memory
inability to concentrate due to pain
conscious
no alteration in reflexes noted


Skin:
skin deep brown
Dry and warm to touch
Good skin turgor
Hair Black in color
Evenly distributed
Thick hair, silky
No infection or infestation noted
Nails Convex
Smooth texture
Capillary refill (2 sec)


Laboratories:
URINALYSIS
Color: Lt. Yellow
Appearance: Sl. Turbid
Rxn: 7.0
S.G: 1.010
Albumin: Negative
Sugar: Negative
Pus cells: 3.7
RBC: 1.2
Epithelial cells: Many
Mucus Threads: Rare
Bacteria: Few
Amoarphous Urates: Rare




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