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A.H.

64/Male
HPI
Two years PTA, pt. claimed to have RUQ pain w
hich was colicky in nature, rated as 7/10, radia
ting sometimes to LUQ between 2-5 seconds.
No medications and consultation. He had no f
ever, jaundice or radiation to right scapular ar
ea.
Patient was apparently well until three mons P
TA, above symptoms recurred, still rated as 7-
8/10, associated with epigastric discomfort
and bloatednesd which was aggravated by inta
ke of fatty meal.
He sought consultation to a gastroenterologis
t, and was managed as a case of gastric ulcer.
A whole abdomen UTZ was requested and rev
ealed an incidental finding of gallstones. He w
as referred for surgical evaluation and manage
ment, thus this admission.
Past Medical History
(+)HPN (4 years)
Maintenance: Telmisartan + Amlodipine (Tywn
sta) 40/5 mg/ tablet OD
allergy to leukoplast, with blister formation of
the plastered site
Past Surgical Hx:
VATS (April 2015)
Jobless, non-smoker, non-alcoholic
P.E.
conscious, coherent, not in cp distress
anicteric sclerae, pinkish conjunctivae, non-hy
peremic tonsils
SCE, CBS, RCRR
Soft abdomen, + NABS, non-tender on all quad
rants, tympanitic, (-) Murphy's sign
GNE
Impression
Cholelithiasis
Laboratories
CBC 8/19/16
Hgb 132
Hct 0.40
RBC 4.41
WBC 5.78
seg 49
stab 1
eosinophils 6
lymphocytes 40
monocytes 4
na142mmol/L
k 3.80 mmol/L
createnine 108.21 umol/L
FBS 5.79 mmol/L
cholesterol 5.69 mmol/L
HDL 1.34
LDL 3.76
TG 1.3
Uric acid 295 umol/L
SGPT 48
Prothrombon time
% activity 100%
patient 13.1sec
INR 1.00
xray: