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