Patient Details
|
Medications |
Seretide Accuhaler 250/50mcg 1 puff INH BD Salbutamol MDI 100mcg 1-2 puffs INH PRN Sertraline 100mg PO mane Clexane 40mg S/C nocte Paracetamol 1g PO QID Endone 5-10mg PO Q4h PRN Ondansetron 4-8mg SL Q6h PRN |
|
HPC |
The patient had an upper abdominal ultrasound while in ED after you had seen them. It showed pericholecystic fluid and gallbladder wall thickening indicating cholecystitis. It also showed cholelithiasis with some sludge. The patient had a markedly raised CRP and not tolerating oral intake due to nausea. Tazocin 4.5g IV Q8H was commenced. They had a laparoscopic cholecystectomy the following day with an intra-operative cholangiogram showing retained stones in the duct – which had been removed during the surgery. You are seeing the patient day 2 post procedure and they are developing worsening abdominal pain. The patient is again vomiting, had little appetite and a low-grade fever. |
|
PSxHx |
Nil |
|
PMHx |
Asthma Depression Overweight |
|
Allergies |
NKDA |
|
FHx |
No relevant family history. |
|
SHx |
Patient lives in Armidale with her husband. They have 2 adult children that have moved out of home. She works full time as a manager of a clothing store. Non-smoker and has 4-5 standard drinks a week. |