id : 53 years old female cc : abdominal pain
TRANSCRIPT
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ID : 53 years old female
CC : Abdominal Pain
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PRESENT ILLNESS:53 years old femaleAbdominal pain since three days ago generalized Constant Without radiation Not related to the patient’s position No relation to meals Anorexia: +Last defecation: 2 days agoGas passage : -
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PRESENT ILLNESS:
Vomiting : + Not bloody Non biliary Contained food remnantNo abdominal distentionNo urinary symptomsNo history of feverHematemesis: -Rectorrhagia: -
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Drug history : Negative
Past medical history: History of cholecystectomy 20 years ago History of laparatomy due to
bowel obstruction 10 years ago History of similar symptoms 3
years ago without operation
Family history: Negative
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PHYSICAL EXAMINATION:
Old female, lying on the bed, ill but not toxic
BP: 100/75 PR: 110 T: 37.2 RR: 16
Conjunctiva was not pale, sclera was not icteric, JVP was not elevated
S4 was auscultated in heart examination lungs were normal
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PHYSICAL EXAMINATION:
Abdominal examination : Fatty abdomen with midline
laparatomic scar and drain scar in RUQ Bowel sounds were hypoactive Generalized tenderness No guarding, no rebound tenderness
TR: Not bloody, No tenderness, Empty ampula
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LAB DATA:
Hb 16.4 17.5 15
WBC 6600 6000 7800
neut 88% 84.3% 87.2%
Plt 222 204 142
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LAB DATA: Na: 140.6 K: 3.71 BS: 189 Urea: 48
Cr:0.93 Amylase: 226.2 Ca:8.4 P:2.7 PT:15 PTT:40 INR:1.19 AST:61 ALT:94 ALP:134 U/A: PH: 6 color: yellow Appearance:
Clear WBC: 2-3 RBC: 2-3 EP: 1-2 ABG: PH:7.40 PCO2:27 HCO3:17.5
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Sonography: Liver: normal CBD: 16mm, dilation of intrahepatic
biliary ducts Spleen and kidneys are normal
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Lab data after 1st surgery
WBC: 8200 HB:17.5 PLT: 75200 PTT: 36 PT: 19 INR: 1.6 U/A: prt: 1+
blood: 3+
AST: 44.9 ALT: 22 ALP: 113 ALB: 2.1 Amylase: 161 NA: 141 K: 5.4 Ca: 8 P: 4.3 BS: 74 Cr: 1.1 Urea: 54 CPK: 274 CPK-MB: 49
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Lab data after 2nd surgery
WBC: 5400 HB:8.3 PLT: 30200 PTT: 40 PT: 20 INR: 2
NA: 157 K: 3.8 Ca: 7.6 P: 3.2 BS: 123 Cr: 1.6 Urea: 63.2
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