LAPROSCOPIC CHOLECYSTECTOMY

9/3/2022

 This is an online e-log book to discuss our patient's de-identified health data shared after taking his/her/guardian's informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs..

A 36 year old Female who is farmer by occupation came to the Casuality with ABDOMINAL PAIN.

HISTORY OF PRESENT ILLNESS:

Normal routine of the patient:

She used to get up at 6 a.m in the morning, used to have tea and did some household work, then breakfast at 8 a.m(rice) then used to go for farming, he used to have lunch at 2 which is rice again. She used to return home by 6 in the evening then he used to freshen up and have dinner at 8 PM and sleep after that

The Patient was apparently asymptomatic 3months back then developed pain in right hypochondrium on/off..

She went to a local doctor, symptoms did not subside and then came to our  causality where she was diagnosed with cholithiasis 

 No complaint of Nausea, vomiting also. 

HISTORY OF PAST ILLNESS:

The patient is not a known case of diabetes, epilepsy,tuberculosis,asthma..

PERSONAL HISTORY

- the patient has no loss of appetite

- bladder movements are normal

-no sleep disturbances 

FAMILY HISTORY:

There are no similar complaints in the family members

TREATMENT HISTORY:

The patient is not a known case of drug allergy

GENERAL EXAMINATION:

-Patient is conscious,coherent and cooperative at the time of joining 

-No pallor 

-No icterus

-No lymphadenopathy 

-No cyanosis 

-No clubbing of fingers

-No edema of feet

VITALS - temperature:98.4F

-pulse rate:70 bpm

-respiration rate:18/min

-bp:120/80

-spo2-99%

SYSTEMIC EXAMINATION:

CVS

-no thrills 

-no cardiac murmurs

S1&S2 sounds are heard

RESPIRATORY SYSTEM ::

- Position of trachea is central 

- Bilateral air entry is normal

- Normal vesicular breath sounds heard

- No added sounds

PER ABDOMEN  abdomen is not tender

- no palpable mass or free fluid

CNS

- Patient is conscious

- Speech is present

- Reflexes are normal 

INVESTIGATIONS:

CBP

LFT

URINE EXAMINATION 

Other Reports

PREVIOUS HOSPITAL REPORTS:

3 MONTHS BACK SHE THOUGHT, PAIN IS DUE TO GASTRIC ACIDITY SO SHE USED TO TAKE GASTRIC TABLETS

TREATMENT:

SHE UNDERGONE LAPRPSCOPIC CHOLECYSTECTOMY IN MONDAY..