1. Step 8
1.1. Diagnostic decision
1.1.1. gallblader stones leading to chronic calculus cholecystitis
1.1.2. E.COLI found in blood
1.1.3. mild dilatation in the CBD
1.1.4. cholengitis
1.2. Mechanism
1.2.1. genatics
1.2.2. the formation of stones
1.2.3. obesity
1.2.4. old age
1.3. Presentation
1.3.1. RUQ pain
1.3.1.1. post prandial
1.3.2. jundice
1.3.3. dark urine
1.3.4. pruritis
1.3.5. pale stool
1.4. Supporting data
1.4.1. HISTORY AND PHYSICAL EXAM
1.4.2. elevated liver enzymes
1.4.3. US showed stones in the distal part of the CBD
1.5. 10 minutes
2. Step 7
2.1. Inquiry plan and info gathering
2.1.1. History of presenting complaint
2.1.1.1. pain
2.1.1.1.1. 10 years
2.1.1.1.2. intermittent right upper abdominal pain
2.1.1.1.3. sudden in onset
2.1.1.1.4. constant and sever
2.1.1.1.5. last for several hours
2.1.1.1.6. radiate to the chest wall right scapula
2.1.1.1.7. it is feelt iter scapular region
2.1.1.1.8. not relieved by antiacids
2.1.1.1.9. somtimes assotiated with nousia and vomitting
2.1.1.1.10. fatty food increase her abdominal pain
2.1.1.2. itching
2.1.1.3. little fever for the last 2 days
2.1.1.4. night sweets
2.1.1.4.1. no rigors
2.1.1.5. no waight changes
2.1.1.6. dar urine foor the last 2 weeks
2.1.1.7. pale stool
2.1.2. Previous medical / surgical history
2.1.2.1. mild hypertention
2.1.2.2. mild conjistive heart faliure
2.1.2.3. admitted 5 month ago for cardia faliure because she stopped her medication
2.1.2.4. hestrictomy at 50
2.1.3. Drug history / allergy
2.1.3.1. digoxen
2.1.3.1.1. once daily
2.1.3.2. furosamid
2.1.3.2.1. twice daily
2.1.3.3. puttasiom
2.1.3.3.1. 3 times daily
2.1.3.4. enalapril
2.1.3.4.1. twice daily
2.1.4. Family history
2.1.4.1. her mother had gallstones and her bladder was removed at the age of 45
2.1.4.2. mother died of colon cancer at the age of 60
2.1.4.3. father died with heart attack at 65
2.1.4.4. eldest doughter devoloped gallstones at 40
2.1.5. Social / occupational history
2.1.5.1. primary carrer for her husband
2.1.5.2. no allcohol or smokes
2.1.6. Systemic review
2.1.6.1. hypertension
2.1.7. Physical examination
2.1.7.1. vitals
2.1.7.1.1. plumb woman
2.1.7.1.2. pulse 100 irregularly irregular
2.1.7.1.3. BP 170/100
2.1.7.1.4. temp 37.5
2.1.7.1.5. RR 23
2.1.7.2. jundice
2.1.7.3. scratch mark on the dorsal surfance of the forarm
2.1.7.4. abdominal
2.1.7.4.1. tenderness on the RUQ
2.1.7.4.2. liver edge can be palpated
2.1.7.5. CV
2.1.7.5.1. raised JVP
2.1.7.5.2. APPIX IS PALPBLE lateral to mid clavicular line
2.1.7.5.3. oscultation
2.1.7.5.4. mild ankle edema
2.1.7.6. respiratory
2.1.7.6.1. cripitation of the lung basses
2.1.8. tests results
2.1.8.1. ECG
2.1.8.1.1. ATRIAL FIBRILLATION
2.1.8.1.2. left ventricular hypertrophy
2.1.8.2. x-ray
2.1.8.2.1. cardiomegaly
2.1.8.2.2. both lungs were normal
2.2. 50 minutes
3. Step 6
3.1. Review session 1
3.2. Report new knowledge
3.2.1. billiary tract obstruction
3.2.1.1. signs and symptoms
3.2.1.2. pathophysiology
3.2.1.3. causes
3.2.1.3.1. malignancy
3.2.1.4. diagnosis
3.2.1.5. complications
3.2.2. pancreatitis
3.2.2.1. signs and symptoms
3.2.2.2. pathophysiology
3.2.2.3. causes
3.2.2.4. diagnosis
3.3. 30 minutes
3.3.1. The scribe does not have to write in this step!