Question

Patient Name: Arthur Tapping
Patient Number: 2004-1756-0
Birth Date: 12/07/72
Date: 07/07/04

Chief Complaint/ Present illness:
Mr. Tapping is a 32-year-old obese African-American male who visited the hospital with a chief complaint of postprandial gastralgia. The patient was well two weeks ago when he noticed the gradual onset of intermittent epigastric pain, after eating. Initially each episode lasted for ½ hour, was mild, and located diffusely in the upper abdomen. Over time the episodes lengthened to 1-2 hours, became severe, and localized in the RUQ. As of yesterday, he has vomited three times, and is now anorexic. The patient denies any previous history of abdominal pain, hemorrhoids, recent weight gain or loss, illicit drug use and excessive alcohol consumption. There are no suggestions of prior postprandial symptoms, or jaundice.

Physical Examination:
General: alert, responsive, middle-aged man who is moderately obese, in obvious discomfort.
Vitals: BP 173/80; Temp 98.5F; HR 97bpm;
Skin: clear, no evidence of jaundice
Lymphatics: unremarkable
HEENT: Sclera was icteric, ears, nose, and throat are clear
Chest: unremarkable
Abdomen: Moderately obese with a very tender globular mass in the RUQ. No splenomegaly or hepatomegaly noted on palpation. Rebound tenderness was negative over the RLQ. No ascites noted, or other evidence or portal hypertension. Bowels sounds are normal and no bruits noted.
Pelvic/Rectal: within normal limits, Guaiac negative, significant steatorrhea noted
Extremities: All distal pulses are palpable, no edema noted

Lab tests:
Blood: Within normal limits except for hypercholesterolemia, and hyperbilirubinemia
Urine: Bilirubin 3+
Echo scan gallbladder: Gallbladder is approximately 13 cm in length with four to five spherical calculi visualized each approximately 1.5 cm at their greatest diameter.
Impression:

1. Acute cholecystitis, from cholelithiasis
2. Secondary jaundice
3. Hypertension
4. Exogenous obesity
5. Hypercholesterolemia

Treatment/Plan: Refer patient to a gastroenterologist for an open cholecystectomy surgery with operative cholangiography.

Thomas Nosbod, MD

What surgery is suggested for Mr. Tapping?

Question 1 options:

	Excision of the gallbladder
	Gastric bypass
	Excision of the appendix
	Partial excision of the stomach

Answer 1

ANSWER IS 1. EXCISION OF THE GALL BLADDER

REASON: mr tapping having postprandial gastralia that means he suufering pain after having food in the right upper quadrant area . if it is lower quadrant we can doubt for appendix.gallbladder shows approximately13cm length 1.5 cm greater diameter spherical calculi .

IMPRESSION shows cholicystitisfrom cholilithiasis.jaundice or hypertension. gastroenterologist suggest open cholecystectomy with cholangiography.which is surgical procedure of removing the gall bladder.

so answer is EXCISION OF THE GALL BLADDER that means A cholecystectomy (koh-luh-sis-TEK-tuh-me) is a surgical procedure to remove your gallbladder — a pear-shaped organ that sits just below your liver on the upper right side of your abdomen. Your gallbladder collects and stores bile — a digestive fluid produced in your liver.

• Gastric bypass surgery refers to a surgical process in which the stomach is divided into a small upper pouch and a much larger lower "remnant" pouch and then the small intestine is rearranged to connect to both. Surgeons have developed several different ways to reconnect the intestine, thus leading to several different gastric bypass procedures (GBP).

• The doctor removes your appendix through a 4-inch-long cut or with a device called a laparoscope (a thin telescope-like tool that lets them see inside your belly). This procedure is called laparoscopy. If you have peritonitis, the surgeon will also clean out your belly and drain the pus.

• Partial excision of stomach or A partial gastrectomy is the removal of a part of the stomach. The lower half is usually removed. A full gastrectomy is the removal of the entire stomach. A sleeve gastrectomy is the removal of the left side of the stomach. This is usually performed as part of a surgery for weight loss