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Abstract: The patient is a 24-year-old female, complaining of sudden paroxysmal pain in the right upper abdomen without fever in recent days, accompanied by yellowish skin, chest tightness, cough, abnormal urination and defecation, etc. After systematic testing, she could be diagnosed as gallbladder stones combined with cholecystitis, and after communicating with the patient, she was treated with surgery and medication, and her condition has been significantly controlled and her body is recovering well.
Basic information】Female, 24 years old
Type of disease】Gallbladder stones combined with cholecystitis
Hospital】The First Affiliated Hospital of Xi’an Jiaotong University
Date of Consultation】August 2020
Treatment plan】Surgical treatment (trans-laparoscopic cholecystectomy) + medication (amoxicillin capsules, etimesine sulfate sodium chloride injection)
[Treatment cycle] In-hospital treatment for 4 days, 1 month after discharge for review
Effectiveness of treatment】The condition has been significantly controlled, and the symptoms of epigastric paroxysmal pain, skin yellowing, and chest tightness have disappeared
I. Initial consultation
When I first saw the patient, he reported that he had been experiencing paroxysmal pain in the right upper abdomen, yellow skin staining, coughing, coughing, and abnormal urination and defecation for the past 4 days without any reason, and was not accompanied by fever. I first made a preliminary inquiry with the patient and learned that he was in good physical condition with no previous history of hepatitis, hypertension, cerebrovascular, or psychiatric diseases. Physical examination revealed no abnormalities in his face, breathing, or heart rate, but there was a positive Murphy’s sign, and ultrasound examination showed a hyperechoic mass in the gallbladder with a posterior acoustic shadow. Combining the patient’s symptoms, signs and ultrasound findings, the patient was initially diagnosed with gallbladder stones combined with cholecystitis, and was advised to take surgical and pharmacological treatment.
II. Treatment history
After the patient agreed to the surgery, routine blood tests and electrocardiogram were performed on the patient, and no contraindication to transperitoneal cholecystectomy was found, so the patient was scheduled for transperitoneal cholecystectomy as soon as possible. There was no obvious bleeding during the operation, and the patient returned to the ward safely after waking up. After the operation, the patient was given amoxicillin capsules and etimesine sulfate sodium chloride injection for anti-infection treatment. In addition, the family members were also informed to call the medical staff in case of any postoperative adverse phenomena.
III. Treatment effect
On the 1st postoperative day, the patient was stable, with good mental status, relatively stable body temperature, pulse, respiration and other vital signs, no bleeding from the small incision dressing, and could properly get out of bed and eat normally, indicating that the patient’s surgery went well. On the third day after surgery, there were no obvious discomfort symptoms, urine and stool were normal, the condition had been obviously controlled, epigastric paroxysmal pain, skin yellowing and chest tightness disappeared, the auxiliary material at the incision was found to be dry and without exudation when changing medicine, and no hyperechoic mass was seen during the review of color ultrasound, combined with the patient’s recovery, he was discharged from the hospital, and there was no adverse condition when reviewed one month after discharge.
IV. Precautions
After discharge from the hospital, I instructed the patient to avoid consuming large amounts of irritating foods such as chili, burgers, beer, hot pot, etc. He should eat a light diet and eat more high-protein foods such as milk, eggs, fish and soybean skin as appropriate to prevent improper diet from affecting the recovery of his body. The surgical incision site should not be exposed to water or scratched by hand for a short time to prevent infection of the incision. The anti-infective drugs prescribed were repeatedly instructed to be taken on time and in the right amount. If the pain in the upper left abdomen, yellowing of the skin, nausea and other adverse phenomena occur again after discharge from the hospital, it is necessary to immediately consult a doctor, and at this time, you should not take medication on your own to prevent covering up the condition and delaying the treatment.
V. Personal insight
The causes of gallbladder stones combined with cholecystitis are complex and related to various factors, such as diet and infection, and are often accompanied by different degrees of epigastric pain, yellow skin staining, belching and other adverse phenomena. If you feel any abnormality in your body, you should seek medical treatment in time, at least through examination to determine the cause and treatment, so as to reduce your discomfort.