Identification data Diagnose Chief complaint History of present illness Past medical history, past surgical history, present surgical history, personal history, family, history, journal, physical exam examination, Vital sign, data or investigation chart, medication chart For a patient of cholelithiasis
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Complete Clinical Case: Cholelithiasis (Gallstones)
1. IDENTIFICATION DATA
| Field | Details |
|---|---|
| Name | Mrs. Sunita Sharma (sample name) |
| Age | 42 years |
| Sex | Female |
| Marital Status | Married |
| Occupation | Homemaker |
| Religion | Hindu |
| Address | 12, Green Colony, City |
| Date of Admission | 12 July 2026 |
| Date of Examination | 12 July 2026 |
| IP Number | 2026-07-0145 |
| Informant | Patient herself (reliable) |
2. DIAGNOSIS
Primary Diagnosis: Symptomatic Cholelithiasis (Gallstones in the Gallbladder)
ICD-10 Code: K80.20 - Calculus of gallbladder without cholecystitis
3. CHIEF COMPLAINT
Recurrent right upper quadrant (RUQ) abdominal pain for the past 3 months, worsening over the last 1 week.
4. HISTORY OF PRESENT ILLNESS
The patient, a 42-year-old obese female, was in her usual state of health until 3 months ago when she began experiencing episodes of right upper quadrant and epigastric pain. The pain is:
- Onset: Insidious, 3 months ago; sudden worsening over the past week
- Site: Right upper quadrant and epigastric region
- Character: Dull, continuous, and severe (described as "colicky" by the patient); not truly intermittent - more of a constant ache during attacks
- Radiation: Radiates to the right shoulder and back
- Duration: Each episode lasts several hours (2-5 hours)
- Frequency: Multiple episodes per week; worse over the past 7 days
- Aggravating factors: Fatty/fried meals, large meals; pain often starts at night and wakes the patient from sleep
- Relieving factors: Partial relief with antispasmodics; vomiting sometimes provides temporary relief
- Associated symptoms:
- Nausea and vomiting (present)
- Dyspepsia and flatulence (present)
- Intolerance to fatty foods (present)
- Low-grade fever (37.8°C) since 2 days (suggesting possible early acute cholecystitis)
- Mild jaundice - absent
- Dark urine/pale stools - absent (no choledocholithiasis)
- No rigors or chills
- Course: Episodic, with periods of improvement followed by recurrence. Last 4 days worsening without full recovery between attacks.
Source: Bailey and Love's Short Practice of Surgery 28th Edition; The Washington Manual of Medical Therapeutics
5. PAST MEDICAL HISTORY
| Condition | Status |
|---|---|
| Hypertension | Present - diagnosed 2 years ago, on medication |
| Diabetes Mellitus | Absent |
| Previous similar episodes | Yes, mild episodes ~1 year ago (not investigated) |
| Peptic ulcer disease | Absent |
| Hepatitis / jaundice | Absent |
| Tuberculosis | Absent |
| Asthma / respiratory disease | Absent |
| Blood transfusions | Absent |
| Allergies | No known drug allergies |
6. PAST SURGICAL HISTORY
| Procedure | Year | Remarks |
|---|---|---|
| Lower segment caesarean section (LSCS) | 2010 | Uncomplicated, uneventful recovery |
| No other surgeries | - | - |
7. PRESENT SURGICAL HISTORY
Indication for current admission: Symptomatic cholelithiasis with frequent biliary colic, now with low-grade fever suggesting possible early acute cholecystitis. Planned evaluation for laparoscopic cholecystectomy.
8. PERSONAL HISTORY
| Aspect | Details |
|---|---|
| Diet | Non-vegetarian; high-fat, high-calorie diet |
| Appetite | Decreased recently due to pain |
| Sleep | Disturbed - pain wakes patient at night |
| Bowel habits | Regular, formed stools; no change in color |
| Bladder habits | Normal, no dark urine |
| Menstrual history | Regular cycles, 28-day cycle, LMP: 28 June 2026 |
| Obstetric history | G2P2L2 - 2 live children (NVD + LSCS) |
| Oral contraceptives | Used for 5 years (risk factor for cholesterol gallstones) |
| Smoking | Non-smoker |
| Alcohol | Non-alcoholic |
| Physical activity | Sedentary lifestyle |
| BMI | 30.2 kg/m² (obese) - major risk factor |
Obesity, female gender, parity, oral contraceptive use, and sedentary lifestyle are established risk factors for cholelithiasis. - The Washington Manual of Medical Therapeutics; Fischer's Mastery of Surgery 8th ed.
9. FAMILY HISTORY
| Member | Condition |
|---|---|
| Mother | Gallstones (underwent cholecystectomy at age 48) |
| Father | Hypertension, Type 2 Diabetes |
| Siblings | No known biliary disease |
| Children | Healthy |
Significance: Positive family history (maternal) - genetics play a role in cholesterol gallstone formation. - Fischer's Mastery of Surgery
10. JOURNAL / CLINICAL NOTES
| Date | Entry |
|---|---|
| 12/07/2026 | Patient admitted with 3 months of recurrent RUQ pain, worsened for 1 week. H/o fatty food intolerance. O/E: RUQ tenderness +, Murphy's sign equivocal. Investigations sent. USG abdomen ordered. |
| 12/07/2026 (Evening) | USG abdomen report confirms multiple gallstones (0.5-1.5 cm), gallbladder wall thickening (4 mm). No CBD dilatation. Surgeon informed. |
| 13/07/2026 | Pain controlled with IV antispasmodics. Diet: low fat, clear fluids. Surgical team reviewed - planned for elective laparoscopic cholecystectomy. Fitness assessment ordered. |
11. PHYSICAL EXAMINATION
General Examination
| Parameter | Finding |
|---|---|
| Conscious and oriented | Yes - alert, cooperative |
| Built and nourishment | Moderately built, well-nourished, overweight |
| Pallor | Absent |
| Icterus/Jaundice | Absent |
| Cyanosis | Absent |
| Clubbing | Absent |
| Lymphadenopathy | Absent |
| Edema | Absent |
| Dehydration | Mild (due to vomiting and poor oral intake) |
Systemic Examination
Abdomen:
| Finding | Detail |
|---|---|
| Inspection | Abdomen mildly distended; no visible peristalsis; no distended veins |
| Palpation | Tenderness in the right hypochondrium and epigastric region; mild guarding present; no rigidity |
| Murphy's sign | Positive - tenderness elicited on deep inspiration during palpation of the right subcostal area (pathognomonic of acute cholecystitis) |
| Gallbladder | Not distinctly palpable (gallbladder distension walled off by omentum) |
| Liver | Not palpable below costal margin |
| Spleen | Not palpable |
| Percussion | Normal tympanic; no shifting dullness |
| Auscultation | Bowel sounds present and normal |
Cardiovascular System: S1 S2 heard, no murmurs; HR 88 bpm, regular.
Respiratory System: Air entry bilateral equal; no added sounds.
CNS: No focal neurological deficits; GCS 15/15.
Murphy's sign is the hallmark physical sign of acute cholecystitis - Bailey and Love's Short Practice of Surgery 28th Edition
12. VITAL SIGNS
| Parameter | Value | Normal Range |
|---|---|---|
| Temperature | 37.8°C (100°F) | 36.5 - 37.5°C |
| Pulse Rate | 88 beats/min, regular, good volume | 60-100 bpm |
| Respiratory Rate | 18 breaths/min | 12-20/min |
| Blood Pressure | 138/88 mmHg (right arm, sitting) | <120/80 mmHg |
| SpO2 | 98% on room air | >95% |
| Weight | 74 kg | - |
| Height | 156 cm | - |
| BMI | 30.4 kg/m² | 18.5-24.9 |
| Pain Score (VAS) | 6/10 | 0 = no pain |
13. DATA / INVESTIGATIONS CHART
Hematological Investigations
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| Hemoglobin (Hb) | 11.8 g/dL | 12-16 g/dL (F) | Mildly low |
| Total WBC Count | 11,200/mm³ | 4000-11,000/mm³ | Mildly elevated (inflammation) |
| Neutrophils | 78% | 55-70% | Elevated (acute inflammation) |
| Lymphocytes | 18% | 20-40% | - |
| Platelet Count | 2.8 L/mm³ | 1.5-4.5 L/mm³ | Normal |
| ESR | 32 mm/1st hour | <20 mm/hr (F) | Elevated |
| CRP | 24 mg/L | <10 mg/L | Elevated (supports diagnosis) |
Biochemical Investigations
| Test | Result | Normal Range | Interpretation |
|---|---|---|---|
| S. Bilirubin (Total) | 1.2 mg/dL | 0.3-1.2 mg/dL | Upper normal |
| S. Bilirubin (Direct) | 0.3 mg/dL | <0.3 mg/dL | Normal |
| SGOT (AST) | 38 U/L | 10-40 U/L | Upper normal |
| SGPT (ALT) | 42 U/L | 7-40 U/L | Mildly elevated |
| Alkaline Phosphatase (ALP) | 110 U/L | 44-147 U/L | Normal |
| GGT | 55 U/L | 5-55 U/L | Upper normal |
| S. Albumin | 3.8 g/dL | 3.5-5.0 g/dL | Normal |
| S. Amylase | 68 U/L | 30-110 U/L | Normal (no pancreatitis) |
| S. Lipase | 72 U/L | 10-140 U/L | Normal |
| Blood Urea | 24 mg/dL | 15-40 mg/dL | Normal |
| S. Creatinine | 0.9 mg/dL | 0.6-1.2 mg/dL | Normal |
| Fasting Blood Sugar | 98 mg/dL | 70-100 mg/dL | Normal |
| S. Cholesterol | 224 mg/dL | <200 mg/dL | Mildly elevated (risk factor) |
| S. Triglycerides | 185 mg/dL | <150 mg/dL | Mildly elevated |
Urine Analysis
| Test | Result |
|---|---|
| Color | Yellow, clear |
| Bilirubin | Absent |
| Urobilinogen | Normal |
| Protein | Absent |
| Sugar | Absent |
| Microscopy | Normal |
Normal urine bilirubin rules out significant bile duct obstruction (choledocholithiasis).
Radiological Investigations
| Investigation | Findings |
|---|---|
| Ultrasound Abdomen (USG) | Multiple hyperechoic foci in gallbladder with posterior acoustic shadowing, consistent with multiple gallstones (largest 1.4 cm). Gallbladder wall thickness: 4 mm (borderline thickened). No pericholecystic fluid. CBD: 5 mm (not dilated). No intrahepatic biliary dilatation. Liver echotexture normal. |
| Chest X-ray (PA view) | Normal; no pneumonia; no free gas under diaphragm |
| ECG | Normal sinus rhythm; no ischemic changes |
Note: Ultrasound has >95% sensitivity and specificity for diagnosing gallstones. - The Washington Manual of Medical Therapeutics
14. MEDICATION CHART
| S.No | Drug | Dose | Route | Frequency | Indication |
|---|---|---|---|---|---|
| 1 | Inj. Diclofenac sodium | 75 mg | IM | SOS (for pain >6/10) | Analgesia for biliary colic |
| 2 | Inj. Hyoscine butylbromide (Buscopan) | 20 mg | IV | 8 hourly | Antispasmodic - relieving biliary colic |
| 3 | Inj. Ondansetron | 4 mg | IV | 8 hourly | Anti-emetic |
| 4 | Inj. Normal Saline | 500 mL | IV | 8 hourly | Fluid replacement (mild dehydration) |
| 5 | Tab. Amlodipine | 5 mg | PO | Once daily (morning) | Hypertension |
| 6 | Tab. Pantoprazole | 40 mg | PO | Once daily (empty stomach) | Gastroprotection / dyspepsia |
| 7 | Tab. Ursodeoxycholic acid | 300 mg | PO | Twice daily | Bile acid replacement (pre-op / adjunct) |
| 8 | Diet | Low-fat, clear fluids | Oral | As tolerated | Reduce gallbladder stimulation |
Planned surgical intervention: Laparoscopic cholecystectomy (elective, after fitness clearance) - the gold standard treatment for symptomatic cholelithiasis. - Maingot's Abdominal Operations
Summary
This is a 42-year-old obese female with the classic "4F" profile (Fat, Female, Forty, Fertile) presenting with symptomatic cholelithiasis. The diagnosis is confirmed by:
- Positive Murphy's sign on examination
- Elevated WBC and CRP (Tokyo Guidelines criteria met)
- USG showing multiple gallstones with borderline gallbladder wall thickening
Management will proceed with laparoscopic cholecystectomy - the gold standard for symptomatic gallstone disease, performed in over 600,000 patients annually in the US alone.
Sources: Bailey and Love's Short Practice of Surgery 28th Edition; Washington Manual of Medical Therapeutics; Maingot's Abdominal Operations; Fischer's Mastery of Surgery 8th Edition
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