Name: LASTNAME,FIRSTNAME Unit No: 9999998
Admission Date: 28/06/89 Discharge Date: 02/07/89
Date of Birth: 01/01/1960 Sex: F
Service: MEDICINE
Allergies:
Azithromycin
Attending: COLERIDGE,SAMUEL T.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient has a history of known illnesses including a
diagnosis of Asthma. There was no obvious inciting event
prior to the onset of pain. She denies vomitting, fevers,
and diarrhea.
In ER:
VS: 97.8 85 120/60 16 100%
Studies: Abd US: Slightly distended gallbladder. Positive Murphys
sign. Probable Cholecystitis. HIDA may confirm.
EKG: NSR.
Fluids: 2L NS
Meds: Morphine 4mg IV x 1
Consults called: gen surgery: Rec HIDA scan.
Review of Systems:
(+) Per HPI
(-) Denies a whole bunch things.
Past Medical History:
- h/o DVT (1985), currently not on anti-coag
- h/o kidney stones
Social History:
Married, has 9 children, lives with husband.
Denies EtOH, tobacco, IVDU.
Family History:
not relevant
Physical Exam:
VS: 98.0 118/65 83 18 100%RA, 2/10 RUQ pain
GEN: Alert
HEENT: no trauma
CV: regular rate and rhythm
GI: + Murphy's sign, soft, non-tender, no rebound
EXT: no edema
NEURO: intact, 5/5 motor function globally
DERM: no lesions appreciated
Pertinent Results:
29/06/89 06:00PM URINE UCG-NEGATIVE
29/06/89 06:00PM URINE COLOR-Yellow APPEAR-Clear SP GRAV-1.005
29/06/89 05:10PM WBC-7.0# RBC-4.05 HGB-11.2 HCT-38.9 MCV-90
MCH-27.4 MCHC-31.5 RDW-15.0
29/06/89 05:10PM PLT COUNT-150
LIVER OR GALLBLADDER US
FINDINGS:
The gallbladder is slightly distended with a 1.5-cm gallstone.
IMPRESSION:
Mildly distended gallbladder containing a single gallstone.
The study and the report were reviewed by the staff radiologist.
HIDA scan: Normal hepatobiliary scan.
Brief Hospital Course:
29 yo F admitted with right upper quadrant abdominal pain.
The patient presented with known gallstone disease. Gallstone found.
HIDA scan was normal. Pain resolved over a day. She should follow-up
with her PCP for repeat LFT's.
Medications on Admission:
Gabapentin prn headache
Discharge Medications:
1. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Asthma
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with right upper quadrant abdominal pain.
Your primary care doctor will help you to decide whether or not you
should consider having your gallbladder removed. Please take all
of your home medications as prescribed.
Followup Instructions:
Follow-up with your primary care doctor within the next 1-2
week.
Name: TOMCAT,MARJORIE YOUNG
Location: HARVARD VANGUARD MEDICAL ASSOCIATES
Address: 133 BROOKLINE AVE, BOSTON,MA, 02215
Phone: 617-555-1234
Appointment: Friday, July 14th at 11AM
SAMUEL T. COLERIDGE MD 12-ABC
Completed by: SAMUEL T. COLERIDGE MD 12-ABC 02/07/89 @ 1021