Department of Surgery

Surgical Clerk: Corsino, John Frederick

I. GENERAL INFORMATION

This is the case of Custodio, Ramel 46 years old, Male, Filipino, Roman Catholic, and a resident of
Molo Iloilo, this is his first admission at Iloilo Doctors Hospital, seen and examine last August 9,
2023. Informant is the patient himself with 95% reliability.

II. CHIEF COMPLAINT

RIGHT UPPER QUADRANT PAIN

III. HISTORY OF PRESENT ILLNESS

2 years prior to consult, onset of RUQ pain, pricking in quality, non-radiating, with a pain Scale of
2/10. The patient sought no consultation and no medications was taken.

In the interim, the RUQ pain persisted and slowly increasing.

1 month prior to admission, the patient complained of severe RUQ pain, now radiating to the
back ang upper thigh hence the consultation to a private hospital wherein Series of laboratories
and imaging was requested and done. Whole abdominal Ultrasound (07-27-23) revealed an
impression of cholecystolithiasis. Due to high volume of patients in the hospital, he opted
another consultation at IDH clinic.

3 days prior to admission patient seek consult to a private physician, symptoms persisted and
was advised for surgery.

IV. PAST MEDICAL HISTORY

Patient is a known hypertensive. (Usual Blood pressure 120/60 Controlled)

Maintenance Medicines (Losartan 50mg, Atorvastatin 40mg)
No Diabetes, no previous surgeries, no food and drug allergies

V. FAMILY HISTORY

Both sides of the family have history of hypertension

VI. PERSONAL HISTORY

Patient worked as a driver for USWAG Party list for 2 years

Patient is not married but has a live in partner, 2 kids
Usual diet: Fatty foods, meats.
Non-smoker
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
Alcohol beverage drinker: 3 bottles of beer/ week.

PHYSICAL EXAMINATION

Patient came in awake, alert, ambulatory, conversant and oriented to time, space and person, not in
cardiopulmonary distress

VITAL SIGNS AND ANTHROPOMETRIC DATA

Results Normal Values Interpretation

Temperature 36.7 C 36.5- 37.5 °C Normal
Heart Rate 92 bpm 60-100 Normal
beats/minute
Respiratory Rate 17 cpm 14-20 cycles/minute Normal
Blood Pressure 120/80 mmHg <120/<80mmHg Normal (Controlled)
Oxygen saturation 98% >95% Normal
Height 170cm
Weight 73kg
BMI 25.3 Normal weight Overweight
18.5–24.9

SKIN Soft, warm, brownish, no lessions

HEENT Head was normocephalic and symmetric with absence of scars, lesions, and
deformities. Hair is black, dry, thin, straight, and evenly distributed. Palpation: No
lesions, deformities, depressions, bulging or masses.
Anicteric sclera, pinkish palpebral conjunctiva

CARDIOVASCULAR Inspection: Precordium was adynamic. Point of maximal impulse at 5th intercostal
space left midclavicular line.
Palpation: No heaves and thrills. Percussion: No cardiac dullness.
Auscultation: Heartbeat regular rate and rhythm. No gallops or murmurs heard.
RESPIRATORY Inspection: No chest deformities. No use of accessory muscles. Ribs were
symmetrical. No lumps, scars, retractions, rashes, and petechiae was noted. Trachea,
and sternum were located medially. No nasal flaring.
Palpation: Symmetric chest expansion. Tactile fremitus was present bilaterally and
are equal.
Percussion: Resonant on all lung fields.
Auscultation: No adventitious breath sounds heard over lung fields.
ABDOMEN Inspection: Abdomen was flat. No scars, ulcers, prominent veins, striae, or masses
seen.
Palpation: Abdomen was dry and warm. Tenderness on RUQ (7-8/10 Pain). Radiation
of pain at the back and lower buttocks, No abdominal masses felt. Liver was palpated
to be firm and non-tender with smooth liver edge. Kidneys and spleen were non
tender upon palpation.
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
Percussion: Tympanic over all 4 quadrants.
Auscultation: Normoactive bowel sounds of 20 clicks per minute. No aortic, renal, or
iliac bruits heard.
(+) Murphy's sign
MUSCULOSKELETAL Full range of motion of upper and lower extremities, Full pulses, CRT <2s

ADMITTING IMPRESSION

ACUTE CALCULOUS CHOLECYSTITIS

DIAGNOSTIC FLOW SHEET

WHOLE ABDOMEN UTZ (7/27/23)

Liver is normal in size and parenchymal echopattern. No focal masses seen. Intrahepatic ducts are not
dilated. Common bile duct measures 0.4 cm
Gall bladder is not enlarged. Gall bladder wall is not thickened. There are multiple high intensity
echoes with posterior sonic shadowing within the gall bladder lumen, largest measuring 2.3 cm(L).

No significant disparity in size of kidneys

Central echo complexes are intact. The corticomedullary demarcations are well defined. There are at
least 2 cysts in the left kidney, the largest measuring 1.6 x 1.3 cm along the medial side in the
midportion of the left kidney. No lithiasis seen.

IMPRESSION
CHOLECYSTOLITHIASIS
SIMPLE RENAL CYSTS, LEFT
NORMAL LIVER, PANCREAS, SPLEEN, RIGHT KIDNEY, URINARY BLADDER AND PROSTATE
ULTRASONOGRAPHICALLY

CHEST PA/Lateral LT (7/13/23)

Lungs are clear

Trachea is at midline
Heart is not enlarged
Costophrenic sulci are intact
Hemidiaphragms are smooth
Rest of the findings are unremarkable

Impression
Essentially Negative Cardiopulmonary Findings

CLINICAL CHEMISTRY (8/7/23)

 Department of Surgery
Surgical Clerk: Corsino, John Frederick
FBS 4.19 4.1-5.9
BUN 5.38 2.5-6.4
CREATININE 133.02 49-115
BLOOD URIC ACID 480.33 155-428
TOTAL CHOLESTEROL 4.17 1.3-5.2
TRIGLYCERIDES 1.41 0.17-1.70
HDL 1.14 0.90-1.55
LDL 2.39 0-3.9
SODIUM 141.70 135-145
POTASSIUM 3.95 3.5-5.3
ALKALINE PHOS 107 50-136
SGPT 40.80 12-78
SGOT 26 15-37

Hematology

Examination(8/7/23) Result Reference Value

Hemoglobin 149 135-180 g/L
Hematocrit 0.44 0.40-0.54 L/L
Red blood cells 4.65 4.2-6.0 x
White blood cells 4.91 10^12/L
Segmenters 0.54 0.50-0.70
Lymphocytes 0.36 0.22-0.40
Eosinophil 0.03 0.02-0.04
Monocytes 0.06 0.03-0.08
Basophil 0.01 0.00-0.01
MCH 32.10 25-34 pg
MCV 93.80 80-100 fl
MCHC 34.20 32-36 g/dL
PLATELETS 267 150-450 x
10^9/L

URINALYSIS

MACROSCOPIC EXAMINATION 8/14/23

RESULT
Color Straw
Transparency Slightly Hazy
pH level 6
Reaction Acidic
Specific Gravity 1.010
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
CHEMICAL EXAMINATION
Sugar NEGATIVE
Bilirubin NEGATIVE
Ketone NEGATIVE
BLOOD NEGATIVE
Albumin TRACE
Urobilinogen NEGATIVE
Nitrite NEGATIVE
Leukocytes NEGATIVE
WBC PUS CELLS(Microscopic) 2-4/HPF
RBC(Microscopic 1-2/HPF
Squamous cells Moderate
Crystals Amorphous urates FEW
Bacteria Occasional

THERAPEUTIC FLOW SHEET

Ceftriaxone Sulbactam Ceftriaxone is a third-generation Ceftriaxone-Sulbactam is used in

(stacef plus) 750mg IV
cephalosporin antibiotic with an
extended spectrum of activity and
increased potency against Gram-
negative bacteria including the
Enterobacteriaceae, Haemophilus
influenza, Moraxella (Branhamella)
catarrhalis, and Neisseria spp.
Sulbactam is a penicillinic acid
sulfone with beta-lactamase
inhibitory properties. It is active
against Neisseriaceae and
Acinetobacter baumanii, but
generally has only weak
antibacterial activity against other
organisms. It is an irreversible
inhibitor of many plasmid-
mediated and some chromosomal
beta-lactamases and has a similar
spectrum of beta-lactamase
the treatment of infections caused
by susceptible organisms including
sepsis, meningitis, abdominal
infections (e.g. peritonitis,
infections of the biliary tract),
infections of the bones, joints, soft
tissue, skin and of wounds, renal
and urinary tract infections,
respiratory tract infections,
particularly pneumonia, and ear,
nose, and throat infections and
uncomplicated gonorrhea.
Ceftriaxone-Sulbactam may also be
used for pre-operative prophylaxis
of infections. A single dose given
pre-operatively may reduce
chances of postoperative infection.
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
Ketoanalogue 600mg
Amlodipine 10mg
Febuxostat 40mg
Parecoxib (Dynastat) 40mg IVTT
Tramadol + Paracetamol 1 tab
inhibition to clavulanic acid (p250).
Although it is regarded as less
potent. Sulbactam can therefore
enhance the activity of penicillins
and cephalosporins against many
resistant strains of bacteria.
Ketoanalogue allows the intake Prevention and therapy of
of essential amino acids damages due to faulty or deficient
while minimizing the protein metabolism in chronic
aminonitrogen intake. Following renal insufficiency in connection
ingestion, the ketoanalogues with limited protein in food of ≤40
are transaminated by taking g/day (for adults), ie generally in
nitrogen from non-essential patients with a glomerular
amino acids, thereby filtration rate (GFR) <25 mL/min.
decreasing the formation of
urea by re-using the amino
group. The levels of
accumulating uremic toxins
are decreased
Amlodipine, a dihydropyridine Ca- Antihypertensive drug
channel blocker, reduces
peripheral vascular resistance and
blood pressure by relaxing the
coronary vascular smooth muscle
and coronary vasodilation through
inhibition of Ca ion
transmembrane influx into cardiac
and vascular smooth muscles
Febuxostat is a potent, non-purine, For Hyperuricemia
selective inhibitor of xanthine
oxidase, the enzyme that catalyses
the conversion of hypoxanthine to
xanthine to uric acid. The inhibition
of xanthine oxidase decreases the
serum concentrations of uric acid.
Parecoxib, a prodrug of valdecoxib, For Postoperative pain
is a selective COX-2 inhibitor that
exhibits anti-inflammatory,
analgesic and antipyretic
properties. It decreases the activity
of COX-2 which leads to reduced
formation of prostaglandin
precursors, thereby inhibiting
prostaglandin synthesis.
Tramadol is a centrally acting symptomatic treatment of
opioid analgesic that binds to μ- moderate to severe pain
opiate receptors in the CNS,
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
Etoricoxib 90mg
Rabeprazole (strirab) 20mg
Ondansetron 8mg IVTT
Metoclopromide 10 mg IVTT
Sultamicillin-Tosylate 750mg/tan
leading to inhibited ascending pain
pathways and altered pain
perception and response. It also
inhibits the reuptake of
norepinephrine and enhances the
release of serotonin.
Paracetamol is a para-aminophenol
derivative with analgesic,
antipyretic and weak anti-
inflammatory activity. The exact
mechanism of its analgesic action
is still unknown, but it is believed
to be by activating the descending
serotonergic inhibitory pathways in
the CNS.
Etoricoxib, an NSAID, is an orally For the treatment of postoperative
active, highly selective cyclo- surgery pain
oxygenase-2 (COX-2) inhibitor. Its
anti-inflammatory and analgesic
action is exhibited by inhibition of
prostaglandin synthesis via
inhibition of COX-2.
proton pump inhibitor that For hyper acidity
suppresses the gastric acid
secretion by inhibiting H+/K+
ATPase at the secretory surface of
the gastric parietal cell.
selectively antagonises 5-HT3- For nausea and vomiting
receptor on both peripherally on
vagal nerve terminals and centrally
in the chemoreceptor trigger zone.
substituted benzamide with Prophylaxis of postoperative
prokinetic and antiemetic nausea and vomiting
properties. It accelerates gastric
emptying and intestinal transit
time by stimulating the motility of
the upper gastrointestinal tract and
increasing gastric peristalsis
without stimulating gastric, biliary
or pancreatic secretions.
Additionally, it blocks dopamine
receptors and serotonin receptors
in the chemoreceptor trigger zone
of the CNS.
Sultamicillin is a prodrug of broad-spectrum antibiotic
ampicillin and sulbactam linked as
a double ester. Ampicillin prevents
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
bacterial cell wall synthesis by
binding to 1 or more of the
penicillin-binding proteins resulting
in inhibition of the final
transpeptidation step of
peptidoglycan synthesis in the
bacterial cell walls. Sulbactam
extends the spectrum of ampicillin
activity due to its irreversible
inhibition of β-lactamases that are
found in penicillin-resistant
organisms.

CASE DISCUSSION

This is the case of a 46/M who came in with RUQ pain and managed as Acute calculous cholecystitis

Salient Points include

• HPI
o Right upper quadrant pain that radiates to the back and buttocks
• PMH
o Hypertensive
• Family
o Hypertensive
• Personal History
o Alcoholic drinker
o Fatty food diet
• PE
o (+) Murphy sign

Acute calculous cholecystitis is a medical condition characterized by inflammation of the gallbladder,

usually triggered by the obstruction of the cystic duct by a gallstone. The gallbladder is a small organ
located under the liver that stores bile produced by the liver until it's needed for digestion. Cholecystitis
can be either acute (sudden and severe) or chronic (recurring over time).

Gallstone Obstruction: The primary cause of acute calculous cholecystitis is the blockage of the cystic
duct by a gallstone. This obstruction leads to the accumulation of bile in the gallbladder, causing
distension and irritation of the gallbladder walls. In some cases, the obstruction can also lead to
infection.

The accumulation of bile and the resulting irritation of the gallbladder walls trigger an inflammatory
response. This leads to symptoms such as severe abdominal pain (often in the upper right quadrant),
tenderness, fever, nausea, vomiting, and potentially jaundice (yellowing of the skin and eyes).Diagnosis
of acute calculous cholecystitis involves a combination of clinical evaluation, medical history, physical
 Department of Surgery
Surgical Clerk: Corsino, John Frederick
examination, and imaging studies. Common imaging techniques include ultrasound, which can help
identify gallstones and signs of inflammation in the gallbladder.

The treatment approach for acute calculous cholecystitis often involves a combination of supportive
measures, pain management, and addressing the underlying cause. In most cases, surgery to remove the
gallbladder (cholecystectomy) is the definitive treatment. This can be done either through open surgery
or minimally invasive laparoscopic surgery. If left untreated, acute cholecystitis can lead to serious
complications such as gangrene (tissue death), perforation of the gallbladder, or the formation of an
abscess. These complications can be life-threatening and require urgent medical intervention. In some
cases, if the patient's condition is not severe and surgery is not immediately possible, non-surgical
interventions such as pain management, antibiotics to treat infection, and fasting (to rest the
gallbladder) might be considered. However, surgical removal of the gallbladder remains the most
effective long-term solution. Preventive measures for gallstone formation include maintaining a healthy
weight, adopting a balanced diet, avoiding rapid weight loss or crash diets, and staying physically active.