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Surgery Ww3 Done

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15 views

Surgery Ww3 Done

Uploaded by

Gopagoni Prekshma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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SUGERY Group 3

WARDWORK KHAN, GAZANFAR


GOPAGONI,PREKSHMA
CASE #3 RAMOS, JOSEPH
ROLE, HANNA AIRA
Chief complaint

Left flank pain


GENERAL DATA
► Name: V.P.P
► Age: 49
► Sex :Female
► Nationality: Filipino
► Religion: Roman Catholic
► Status: Married
► Occupation: Food vendor
► Address: Taloy, San Carlos City, Pangasinan
History of Present Illness
► Date of admission: 3/29/24
LABS:
► 6 days PTA, at around 7 pm, the patient experienced left flank pain
UTZ: Bilateral nephrolithiasis, cholelithiasis, focal
► Duration: about 30 minutes caliectasia (L)

► Frequency: Upon waking up and late at night. Sometimes, randomly. Urinalysis: UTI (WBC: TNTC/HPF)

► Precipitating factors: none Hematology: elevated WBC

► Quality: can’t describe “basta sobrang sakit” Clinical Chemistry: elevated triglycerides

► Radiation: lower back

► Severity: Pain scale: 8/10

► Aggravated by standing up, lying flat, straining ,and coughing .

► Alleviated by lying in decubitus position, taking medicol

► Associated signs and symptoms: fever, vomiting, and chills 1 day PTA

1 day PTA, the patient was febrile and had episodes of flank pain with the same
characteristics mentioned above but was accompanied by vomiting and chills
Current Medications

► maintenance medication of Amlodipine 5 mg OD since 2022

► Omeprazole 40 mg

► Ceftriaxone 1g IV

► HNBB 20 mg IV

► Fenofibrate 200mg

► Sambong leaf (RE-LEAF Forte 500mg): anti-urolithiasis / Diuretics

► Potassium Chloride 600mg


PAST MEDICAL HISTORY

► Hypertensive (diagnosed in 2022). Managed with Amlodipine 5 mg OD since 2022.

► (+) allergies : seafood

► Childhood illnesses: chickenpox

► Previous hospitalization: 16 years ago (unspecified “kidney problem”). Managed with Cefuroxime.

SURGICAL HISTORY

► No history of previous surgery


FAMILY HISTORY

► Father: 86 y/o (+)arthritis

► Mother : (+) Diabetes Mellitus , (+) Hypertension (deceased by age 40)

► Familial illnesses
Patient’s Mother and son have Diabetes mellitus

Patient’s husband and son had appendicitis


Menstrual & Obstetric History

► Menarche at 12 y/o, with regular menstruation.

► Duration of period : 5 days

► No.of pads used per day : 4-5

► Age of 1st coitus: 24 y/o

► LMP: 2 years ago

► She has 7 children, all delivered term via NSD without complications (G7P7) [7007)

► Menopause at the age of 47 but spotting was observed on February 2024.


PERSONAL AND SOCIAL HISTORY
► The patient is a midwifery graduate, a food vendor, and
living with her husband since 26 years.

► alcohol consumption: occasionally (soju:1 bottle)

► (-) illicit drug use and cigarette smoking.

► Financial source: Canteen and sari-sari store


NUTRITIONAL HISTORY
► The patient usually eats 3 meals a day which mostly consist of
vegetables, fish, meat, fatty and salty food with 1 cup of rice for each
meal.

► (+)allergies : seafood

► Coffee: 4x/day

► Softdrinks: 3x/day

► Supplement: Centrum advance


ENVIRONMENTAL HISTORY

► Type of residence: bungalow house


► Occupants: husband and kids
► Source of drinking water: refilling station
► Garbage disposal: collection
► Fecal disposal: septic tank
► Pets: 1 dog
REVIEW OF SYSTEMS
GENERAL SURVEY

Constitutional (-) fever, (-) weight gain, (-) chills, (-) fatigue

HEENT (-) baldness, (-) dizziness, (-)double vision, (-) photophobia, (+) use of eyeglasses,
(+) blurred vision, (-) earache, (-) lump, (-) stiffness

Breast (-) pain, (-) lumps, (-) discharge

Cardiovascular (-) palpitations, (-) cyanosis, (-) easy fatigability

Gastrointestinal (+) loss of appetite, (+) vomiting, (+) abdominal pain, (-) hematochezia, (-)
diarrhea, (-) constipation, (+) skin discoloration of the abdomen due to allergy

Respiratory (-) cough, (-) hemoptysis, (-) wheezing, (-) sputum production, (-) dyspnea

Genitourinary (-) dysuria, (+) nocturia(3x per night), (-) incontinence, (-) urinary urgency, (-)
polyuria, (-) urinary retention, (-) pain, (-) discharge, (-) ulcers, (-) swelling
white/yellow colored urine .
Musculoskeletal (-) muscle weakness, (-) backache, (-) muscle pain, (-) stiffness, (-) joint swelling,
(-) joint pain
REVIEW OF SYSTEMS
GENERAL SURVEY

Peripheral vascular (-) Leg cramps, (+) varicose veins

Neurologic (-) paralysis, (-) tremors, (-) memory loss, (-) numbness,
(-) seizures

Hematologic (-) easy bruising, (-) pallor, (-) bleeding

Endocrine (-) Hot/cold intolerance, (-) polydipsia, (-) polyphagia


Physical examination
► GENERAL SURVEY

The patient is conscious, coherent, ambulatory and is oriented to time and space.

► VITAL SIGNS

• Temperature: 36.9 °

• Respiration: 25 breaths per minute

• Pulse: 60 bpm

• Blood Pressure: 100/80 mmHg

• Oxygen saturation: 97%


PHYSICAL ASSESSMENT
ORAL CAVITY
EARS
Lips: normal
► External Ear: The Auricle
Gingiva: normal
• normal in size
Tongue: Normal
• Symmetrical Throat: No lesions, midline, tonsils not enlarged, no exudates, no lesions
• no deformity NECK
• no lumps • Normal in size, Symmetrical
• No visible mass, No deformity
NASAL AND PARANASAL SINUSES
• No swelling, Normal Range of Motion

• Nose: symmetrical • Trachea: Midline


• Thyroid gland: Not visible, not palpable
• Nasal cavity: pink mucosa , no discharge
or bleeding , no swelling no foreign
bodies.
PHYSCIAL ASSESSMENT
CRANIUM EYES
• Hair: Black • Eyelids: Skin intact, close symmetrically,
• Size: Proportional to the body bilateral blinking
• Normocephalic • Eyeballs: Normal set of eyeballs, no
• Symmetric exophthalmos

FACE • Bulbar conjunctiva: normal

• Symmetric • Palpebral conjunctiva: normal

• No lesions • Cornea and iris: Iris are visible, flat and


brown
• Without involuntary movements
• Corneal sensitivity reflex: Blinks when
cornea is touched with corner of cotton
• Pupil: black, equal in size, round, smooth
border
PHYSICAL ASSESSMENT
Abdomen
INSPECTION
Thorax and Lungs • Flat, symmetrical
• Skin: normal • (-) Irregular Contours

• Respiration: 25 cpm • (+) hyperpigmentation and striae

• Respiratory effort: normal PALPATION


• Soft to touch
• Lung expansion: symmetrical
expansion • No masses or swelling
• (+) Pain on left flank with deep palpation
• Normal breath sounds
• (+) murphy's sign
HEART
PERCUSSION
• No murmur
Tympanytic in all 4 quadrants
• PMI at 5th ICS mid-clavicular line
AUSCULTATION
• 5 bowel movements/minute
ULTRASOUND

► Bilateral nephrolithiases

► Cholelithiasis

► Focal caliectasia (left)


LABORATORY
Rbs: 103 Hct: 0.38

Crea: 109.2 Hgb: 127

BUN: 6.5 RBC: 4.6

Na: 139.9 WBC: 13.5

K: 4.3 Segmenters: 0.82

Cl: 103.3 Lymphocytes: 0.18

ALT: 22.1 Triglyceride: 194.5

AST: 15.6 HDL: 35.6

FBS: 6.2 LDL: 144.3

Total cholesterol: 4.36


MEDICATIONS

► Maintenance Medications

Amlodipine 5 mg OD

► Vitamins:

centrum advance
Primary Diagnosis
Nephrolithiasis
Differential Diagnosis
Renal colic: Pain due to other causes such as urinary tract infection, renal
infarction, or renal artery stenosis can mimic the symptoms of nephrolithiasis.
Urinary tract infection (UTI): Infections in the urinary tract, particularly
involving the kidneys (pyelonephritis), can cause similar symptoms.
Appendicitis: Pain from appendicitis can sometimes radiate to the lower back,
mimicking kidney stone pain.
Pelvic inflammatory disease (PID): Inflammation of the female reproductive
organs can cause pelvic pain similar to kidney stone pain.

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