DR BHAGYAVASAN
Tamilnadu, India
Cholelithiasis
Cholelithiasis, commonly referred to as gallstones, is a prevalent medical condition characterized by the formation of solid particles within the gallbladder. These stones can vary in size and composition, and their presence can lead to various symptoms, including abdominal pain, nausea, and even blockages in the bile ducts. While some individuals may remain asymptomatic, those experiencing discomfort or complications may require medical intervention.
- PRILIMINARY DATA:
NAME OF THE PATIENT: XXX
AGE/ SEX: 37/F
ADDRESS: xxxxxxxx, SUNNAMPUKARAL PATTI, ALLIDURAI, PALLAKALU POST, TPJ
PHONE: xxxxxxx870
ATTENDING PHYSICIANS: DR. BHAGYAVASAN K, NOWSHIKA V, JEBA DELPHIN V
DATE OF SYMPTOMS: 10/08/2020
DATE OF ADMISSION: 11/08/2020
- PRESENTING COMPLAINTS
LOCATION | SENSATION | MODALITY | ACCOMPANIMENT |
GASTROINTESTINAL SYSTEM – EPIGASTRIUM SINCE 1 DAY | PAIN>VOMITING, SOUR TASTE | >VOMITING
| DECREASED APPETITIE |
- HISTORY OF PRESENTING COMPLAINTS
THE PATIENT, A 37 YEAR OLD FEMALE, COMPLAINS OF SEVERE PAIN AND TENDERNESS IN THE EPIGASTRIC REGION ASSOCIATED WITH ERRUCTATIONS AND VOMITING OF SLIGHTEST FOOD OR WATER SINCE 1 DAY.
- HISTORY OF PAST ILLNESS
HISTORY OF CBD STONE, BILE STONE, RENAL CALCULI
- GENERALS
PHYSICAL GENERALS: APPETITE: DECREASED THIRST: PRESENT BOWELS: REGULAR BLADDER: REGULAR SLEEP: DISTURBED DUE TO DISCOMFORT WEAK, PROSTATED | MENTAL GENERALS: ANXIOUS+ |
- GENERAL PHYSICAL EXAMINATION
ANAEMIA: PALLOR PRESENT
JAUNDICE: NOT ICTERIC
CYANOSIS: NIL
OEDEMA: NIL
LYMPHADENOPATHY: NIL
CLUBBING: NIL
VITAL SIGNS:
PULSE: 75 bpm
BP: 190/120 mmof Hg
SPO2: 98%
WEIGHT: 57 KG
- INVESTIGATIONS:
CT ABDOMEN AND PELVIS:
SIGNS OF OBSTRUCTIVE BILIOPATHY WITH DILATED IHBD, CHD, CBD. SUSPECTED TERMINAL CBD CALCULUS 1 CM IN LENGTH AND 0.4 CM IN CROSS SECTIONAL DIAMETER. GB DISTENDED. MULTIPLE CALCULI- LARGEST 0.6 CM WITH GB WALL OEDEMA- CALCUS-CHOLECYSTITIS
- DIAGNOSIS: CALCULUS CHOLECYSTITIS+ CBD CALCULI (OBSTRUCTIVE)
- PRESCRIPTION:
RX
CARDUS MARIANA 30 (QIH)(alternated)
BERBERIS VULGARIS 30 (QIH)(alternated)
PHOSPHORUS 30 (single dose)
- PROGNOSIS: PAIN STARTED TO SUBSIDED AND SHE WAS ABLE TO RETAIN FOOD THE FOLLOWING DAY.
- DISCHARGE DATE: 12/08/2020
- CONDITION AT THE TIME OF DISCHARGE: FIT FOR DISCHARGE
- DISCHARGE SUMMARY:
PATIENT COMPLAINT OF PAIN, TENDERNESS IN THE EPIGASTRIC REGION WITH SEVERE ERRUCTATIONS AND VOMITING OF EVEN SLIGHTEST INGESTED FOOD OR WATER. VOMITING >++.
CT IMPRESSION SHOWED CHOLELITHIASIS MEASURING 1 CMS IN LENGTH AND 0.4 CMS IN CROSS SECTIONAL DIAMETER. GB DISTENSION AND GB WALL OEDEMA- CALCULUS CHOLECYSTITIS WAS ALSO FOUND.
CURRENTLY THE PATIENT IS ABLE TO RETAIN FOOD AND PAIN IS SLIGHTLY BETTER.
- NEXT REVIEW DATE: 15/08/2020
- REMARKS: URINE COMPLETE, FBS, PPBS
- FOLLOW UP I:
15/08/2020: Pain slightly better but persist. Nausea and vomiting better. Able to tolerate food and drinks well.
Generals: Good
Investigations:
Bio-Chemistry Blood Sugar Fasting – 115mg/dl Blood sugar (post-prandial) – 140mg/dl
Urine Analysis Urine Complete F — PP Glucose: NIL Bilirubin: NIL Ketones: NIL Ph: 5 Protein: NIL Urobinlinogen: 0.1mg/dl Nitrite NIL Leukocytes NIL micro liter Specific Gravity 1.025 1.025 RBC NIL micro liter |
Prescription:
Rx: REPEAT THE SAME
FOLLOW UP II:
26/08/2020
Epigastric pain since today
Eructation present
Tiredness of body
Dryness of mouth
Vomiting 1 time
Indigestion
Generals: good
Prescription:
Rx
NUX VOMICA 30(4drops morning)
CHOLESTRINUM 3X (2-0-2)
MYRISTICA SEBIFERA Q (10 drops TDS)
THUJA OCCIDENTALIS 200 (SINGLE DOSE)
LYCOPODIUM CLAVATUM 200 (SINGLE DOSE) / X 15 DAYS
Cholelithiasis
Treatment options range from dietary modifications and medications to surgical procedures, such as cholecystectomy, which involves the removal of the gallbladder. Timely diagnosis and appropriate management are essential to alleviate symptoms and prevent potential complications associated with cholelithiasis.
