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Abstract: The patient in this case is a 68-year-old male who presented with right upper abdominal pain a few days before the consultation. Since abdominal pain is often worse after eating, the patient mistook it for indigestion and did not consult the doctor. After taking antipyretic drugs, his body temperature dropped, but his condition was still recurrent, so he went to our hospital and was diagnosed with cholecystitis.
Basic information】Male, 68 years old
Disease Type】Cholangitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】February 2021
Treatment plan】Surgical treatment (laparoscopic cholecystectomy)
Treatment Period】5 days in hospital
Effectiveness】Improvement and disappearance of symptoms
I. Initial consultation
The patient is a 68-year-old male with a history of hypertension for 5-6 years, chronic obstructive pulmonary disease for 5 years, and a history of smoking and alcohol consumption for more than 40 years. Recently, he developed abdominal pain, mainly in the right upper abdomen, often aggravated at night and after eating, but the patient himself mistook it for indigestion and did not pay attention to it immediately until the night before the visit, when his body temperature rose to a maximum of 38.3℃, accompanied by the discomfort of chills. After taking antipyretic medication (the exact name of the medication is unknown), the body temperature dropped, but the fever remained recurrent, so the patient came to our hospital accompanied by his family. A physical examination at the outpatient clinic suggested the presence of abdominal pressure pain and a positive Murphy’s sign, and combined with the patient’s symptoms and complaints, the patient was admitted to the hospital for further treatment as acute cholecystitis was suspected.
Treatment history
After the patient was admitted to the hospital, routine blood tests showed that the white blood cell count was elevated; abdominal ultrasound showed that the gallbladder wall was gross and gallstones were visible. Therefore, the patient could be diagnosed as having acute calculous cholecystitis. The patient’s condition was then communicated to the patient and his family. Considering the patient’s age, the patient was recommended to undergo laparoscopic surgery, which is less invasive and has a faster postoperative recovery. After discussion, the patient and his family agreed to perform laparoscopic cholecystectomy. The patient was then instructed to fast from food and water before surgery, and the gallbladder was removed under general anesthesia. After the operation, the patient’s vital signs and incision were closely monitored to prevent postoperative infections and other complications.
III. Treatment results
After surgical treatment, the patient controlled the inflammation and the development of the disease. After 5 days of hospitalization, the patient was basically free of discomfort and complained of preoperative abdominal pain and other discomfort symptoms, which had completely disappeared, and asked to be discharged voluntarily. After physical examination, the patient’s abdominal incision recovered normally, no redness, swelling, exudate and other symptoms were seen, and the postoperative vital signs continued to remain stable, so the patient was agreed to be discharged for recuperation. One month after discharge, the incision had healed, and the blood routine and abdominal ultrasound were normal.
IV. Notes
With the surgical treatment, the patient’s condition was controlled and no serious complications occurred, and I was happy for the patient’s improvement. At the same time, I reminded the patient’s family that because of the patient’s old age, they should pay attention to the patient’s life and living before the incision is completely healed, to prevent the incision from infection, tearing and other accidents; after discharge from the hospital, they can accompany the patient to walk and do gymnastics every day to promote physical recovery; in addition, they should pay extra attention to the diet not to eat too greasy food, on the one hand, because the patient has hypertension itself, if too much fat intake may On the other hand, after gallbladder removal, the digestive system’s ability to absorb fat will be weakened, so eating food with high fat content may cause diarrhea.
V. Personal insight
Acute cholecystitis often has right upper abdominal pain as the first symptom, especially after eating, and if the diet is greasy, the abdominal pain will be more obvious. When the above symptoms appear, you should be alert to acute cholecystitis and seek medical attention as soon as possible. It is not recommended that this patient take medication at home because acute cholecystitis, once treated with delay, is likely to induce serious complications such as gallbladder perforation and even life-threatening. Therefore, when the body sends abdominal pain and other abnormal signals, should be clearly diagnosed as soon as possible, and parallel surgical treatment to remove the gallbladder, or the correct use of drugs, symptomatic antibacterial pain relief.