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GIT History Report

The patient, Siti Muslila Ali, a 45-year-old Malay housewife, was admitted to the hospital for a laparoscopic cholecystectomy to remove gallstones from her gallbladder. She had a history of abdominal pain and was initially diagnosed with gallstones in September 2013. After being readmitted in January 2014 for worsening pain, an ultrasound confirmed the gallstones had increased in size. She underwent the planned laparoscopic cholecystectomy surgery on January 21st, and was recovering from post-operative pain in the ward. A review of her medical history, family history, social history, and medication history were otherwise unremarkable.

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Yan Chan Hao
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292 views

GIT History Report

The patient, Siti Muslila Ali, a 45-year-old Malay housewife, was admitted to the hospital for a laparoscopic cholecystectomy to remove gallstones from her gallbladder. She had a history of abdominal pain and was initially diagnosed with gallstones in September 2013. After being readmitted in January 2014 for worsening pain, an ultrasound confirmed the gallstones had increased in size. She underwent the planned laparoscopic cholecystectomy surgery on January 21st, and was recovering from post-operative pain in the ward. A review of her medical history, family history, social history, and medication history were otherwise unremarkable.

Uploaded by

Yan Chan Hao
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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BLOCK: GASTROINTESTINAL SYSTEM

History

1. Patients Identification:
Name Age Race Religion Sex Occupation Marital status Patients Address Date of Admission Date of Clerking Reference No. Bed Number K/P Informant : Siti Muslila Ali : 45 : Malay : Islam : Female : Housewife : Married : PT 367, Taman Nazraq, Kampung Pantai Senol. : 20/1/14 : 21/1/14 : B311272 : 3 WS / 14 : 690104-09-5122 : Herself

2. CHIEF COMPLAINS
My patient was admitted to HUSM on 20/1/2014 for laparoscopic cholecystectomy which planned on 21/1/2014.

3. HISTORY OF PRESENTING ILLNESS


Patient admitted to HUSM for laparoscopic cholecystectomy due to multiple small gallstones present in the gall bladder. Around September 2013, patient admitted to hospital Kuala Krai due to abdominal pain at right hypochondriac region associated with vomiting. The pain is dull in nature and not radiating. Pain killer was given and he was referred to HUSM for further assessment. On 9/9/2013, she came to HUSM for checkup. Ultrasound was done and she was told by the doctor that multiple gallstones present in the gallbladder. Thus, laparoscopic cholecystectomy was planned and the surgery will be performed on 21/1/2014. On 10/1/2014, she was admitted to hospital again due to suprapubic abdominal pain associated with nausea and vomiting. The pain was radiated to right hypochondriac region and shoulder. The nature of pain is sharp and not localized. The pain was relieved when she leaned forward. She also said that the pain affected her daily normal activities. There is no aggravating factor. A cup of vomitus was

estimated by her during each time of vomiting. The vomitus is yellowish and contain mostly of water. Her abdomen also slighted distended. Her stools is light brown in colour and oily. She also said that the colour of her urine is slightly yellow compare to normal, like the colour of teh o nipis. She also loss of appetite and weight last few days before admission as she didnt ingest any food due to the abdominal pain. The doctor told her that appendicitis was suspected. On 2nd day of admission, ultrasound was done again. No appendicitis but the gall stones became bigger and the gall bladder was dilated. Oral painkiller was given and IV pain killer was given when severe pain occurs. She was discharged 5 days later after the pain was resolved and appetite returned to normal. Green and yellow capsule pain killer (tramadol 200mg) was given. Slight abdominal distention still present. On 20/1/2014, she admitted to HUSM. On 21/1/2014 morning, surgery was done. She is currently resting in the ward. She feels the pain due to the post-operation.

4. SYSTEMIC REVIEW
a. Cardiovascular System - Absence of chest pain - Absence of blackout without warning - Absence of dizziness - Absence of ankle swelling - Absence of palpitation b. Respiratory System - Presence of dry cough - Chest pain due to cough - Absence of sputum - Absence of fever - Absence of haemoptysis - Absence of lump and breasts discharge - Absence of night sweat c. Musculoskeletal System - Positive finding on numbness of hands and legs - Absence of muscle pain - Absence of muscular deformities - Absence of muscle wasting - Absence of joint pain d. Central Nervous System - Hearing problem after the use of painkiller - Absence of visual problem - Absence of loss of consciousness

Absence of drowsiness

e. Genitourinary System - Absence of painful micturition - Absence of dysuria - Absence of incontinence - Absence of blood in urine f. Endocrine System - Absence of unusual thirty ( DM ) - Absence of increased sweating - Absence of neck swelling g. Reproductive System - Absence of miscarriage - Absence of Caesarean section - Absence of complication during pregnancies and deliveries.

5. PAST MEDICAL HISTORY


My patient had never admitted to any hospital before except for deliveries.. However she visited Hospital Kuala Krai last year due to right hypochondriac pain and was given painkiller and referred to HUSM.

6. PAST SURGICAL HISTORY


My patient had never been through any surgery before.

7. FAMILY HISTORY
My patients father had passed away. She not sure about the age and reason when her father passed away. Her mother, with the age of around 60 years old is still living but with diabetes mellitus, high blood pressure and heart disease. She has 6 siblings. Her 3rd brother died of accident. Her oldest sister, with high blood pressure, died due to stroke attack. Other siblings are living healthily except 2nd younger sister has hypotension. She has 4 children, all of them are living healthily.

8. SOCAL HISTORY
She live in terrace house made of bricks and woods. She said that the surrounding environment of her house are clean. They use well water for laundry and shower and buy mineral water for drinking. She didnt rear any domestic animal around hes house

except fishes. She worked as a cleaner in Celcom company 2 years ago but became housewife after quitting her job as cleaner. She deny of smoking and taking any alcoholic drinks. Her husband also quit smoking 18 years ago.

9. DRUG HISTORY
My patient said she felt dizziness whenever she smell perfume. She admitted of taking collagen supplement daily.

10. SUMMARY
My patient, Siti Muslila Ali, with the age of 45 years old, Malay, housewife, was admitted to HUSM on 9/9/2013 as referred case from Hospital Kuala Krai due to right hypochondriac pain associated with vomitting and was readmitted to HUSM on 10/2/14 due to suprapubic pain. Laparoscopic cholecystectomy was performed on her on 21/1/2014 to remove the gallstone.

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