🏥 MEDICAL REPORT & TREATMENT CHART Patient Name: ______________________________ Age/Sex: ______ Years / ______ UHID/IPD No.: _____________________________ Date: ____ / ____ / 20____ --- CHIEF COMPLAINTS - Pain over right upper abdomen × 2 days - Fever × 1 day - Nausea and vomiting - Loss of appetite --- ON EXAMINATION General Condition: Conscious and oriented Temperature: 38.5°C Pulse: 104/min BP: 118/76 mmHg SpO₂: 98% on room air P/A Examination: - Right hypochondrial tenderness present - Murphy's sign positive - Mild localized guarding present --- BLOOD INVESTIGATION Hb: 12.4 g/dL TLC: 16,800/µL ↑ Neutrophils: 84% ↑ Platelet: 2.85 lakh/µL CRP: 78 mg/L ↑ Total Bilirubin: 1.4 mg/dL Direct Bilirubin: 0.6 mg/dL AST: 42 IU/L ALT: 48 IU/L ALP: 165 IU/L Serum Amylase: 72 U/L Serum Lipase: 46 U/L Serum Creatinine: 0.8 mg/dL RBS: 108 mg/dL --- USG WHOLE ABDOMEN - Gallbladder is distended. - Multiple gallstones noted within gallbladder. - Largest calculus measures approximately 14 mm. - Gallbladder wall thickening measuring approximately 6 mm. - Pericholecystic fluid present. - Sonographic Murphy's sign positive. - CBD measures approximately 5 mm, not dilated. - No intrahepatic biliary radical dilatation. IMPRESSION: USG findings suggestive of ACUTE CALCULOUS CHOLECYSTITIS with CHOLELITHIASIS. --- 🩺 DIAGNOSIS ACUTE CALCULOUS CHOLECYSTITIS --- 💊 TREATMENT 1. Inj. Ceftriaxone 1 gm IV BD 2. Inj. Metronidazole 500 mg IV TDS 3. Inj. Paracetamol 1 gm IV SOS for pain/fever 4. Inj. Ondansetron 4 mg IV SOS for nausea/vomiting 5. Inj. Pantoprazole 40 mg IV OD 6. IV Fluids RL/NS as per hydration status 7. Keep patient NPO initially 8. Monitor vitals regularly 9. Monitor CBC, CRP, LFT and RFT 10. Surgical consultation advised for early laparoscopic cholecystectomy --- Condition: Hemodynamically stable Plan: Conservative management, IV antibiotics, analgesia, supportive care and surgical intervention as advised. Signature & Stamp Dr. __________________________