This document contains a medical history and examination for a patient presenting with cholelithiasis, or gallstones. The patient reports right upper quadrant abdominal pain that is worsened by fatty foods and after meals. A physical exam revealed Murphy's sign was positive. The assessment is cholelithiasis and the plan is for a cholecystectomy or lithotripsy to remove the gallstones, along with medications, diet and lifestyle recommendations to prevent future gallstones.
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This document contains a medical history and examination for a patient presenting with cholelithiasis, or gallstones. The patient reports right upper quadrant abdominal pain that is worsened by fatty foods and after meals. A physical exam revealed Murphy's sign was positive. The assessment is cholelithiasis and the plan is for a cholecystectomy or lithotripsy to remove the gallstones, along with medications, diet and lifestyle recommendations to prevent future gallstones.
This document contains a medical history and examination for a patient presenting with cholelithiasis, or gallstones. The patient reports right upper quadrant abdominal pain that is worsened by fatty foods and after meals. A physical exam revealed Murphy's sign was positive. The assessment is cholelithiasis and the plan is for a cholecystectomy or lithotripsy to remove the gallstones, along with medications, diet and lifestyle recommendations to prevent future gallstones.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online from Scribd
This document contains a medical history and examination for a patient presenting with cholelithiasis, or gallstones. The patient reports right upper quadrant abdominal pain that is worsened by fatty foods and after meals. A physical exam revealed Murphy's sign was positive. The assessment is cholelithiasis and the plan is for a cholecystectomy or lithotripsy to remove the gallstones, along with medications, diet and lifestyle recommendations to prevent future gallstones.
Copyright:
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CHOLELITHIASIS
1. CHIEF COMPLAINT •Cholelithiasis
2. HPI a. Concern: b. Onset- •Sudden •Gradual
c. Duration: ____ •Recent •A few days •Many days •A few weeks •Many weeks •A few months •Many months •A few years •Many years •Recurrent •N/A.
d. Severity: •Mild •Moderate •Severe •Absent •Normal •Increased •Decreased •Stable •No significant change from prior visit. •Details
e. Location: Right upper quadrant/ middle upper abdomen
f. Radiation: •The flanks •Intrascapular regions •Right shoulder g. Quality: •Improving •No change •Worsening •Burning pain •Constricting •Crushing •Dull pain •Heavy •Sharp pain •Squeezing •Stabbing
h. Frequancy i. Status j. Context k. Aggravated by : •worse by fatty or greasy foods •after meal l. Relieved by m. Associated Symptoms •Abdominal fullness •Clay-colored stools •Excess gas •Heartburn •Indigestion •Nausea and vomiting n. Pertinent Negatives o. Notes
3. ROS
4. SYMPTOMS • Abdominal pain in the right upper or middle upper abdomen • Fever • Yellowing of skin and whites of the eyes (jaundice) • Abdominal fullness • Clay-colored stools • Excess gas • Heartburn • Indigestion • Nausea and vomiting 5. HISTORY
a. FAMILY HISTORY •Cholelithiasis •Obesity •Hyperlipidemia •Cystic fibrosis
b. SOCIAL HISTORY
c. PAST MEDICAL HISTORY
•Pregnancy •Obesity •Diabetes •Rapid eight loss •Hyperlipidemia •Cystic fibrosis and pancreatic insufficiency •Crohn's disease •Prolonged parental treatment •Spinal injury
d. SURGICAL HISTORY •Truncal vagotomy •Ileal bypass •Ileal resection e. CHRONIC CONDITIONS •Cystic fibrosis •Crohn’s disease
6. ALLERGIES
7. PHYSICAL EXAMINATION •Pain in right upper quadrant •Murphy’s sign positive
8. SPECIFIC DATA LIKE GRADING
9. TESTS TO BE ORDERED • Liver function test • Alanine aminotransferases • Aspartate aminotransferases • Serum bilirubin • Alkaline phosphatase • Serum lipase • Serum amylase • Complete blood count with differential • Upright and supine abdominal radiographs • Ultrasound • Computed tomography (CT) • Magnetic resonance imaging (MRI) • magnetic resonance cholangiopancreatography (MRCP) • Technetium Tc-99m hepatoiminodiacetic acid (HIDA) scintigraphy • Endoscopic retrograde cholangiopancreatography (ERCP) • Endoscopic ultrasound (EUS) 10. ASSESSMENT/PLAN •Removal of the gallbladder (cholecystectomy) •Extracorporeal shock-wave lithotripsy (ESWL)
11. EDUCATION
•Avoid fat rich diet
•Do regular exercise •Do not undertake aggressive weight loss programs •Avoid high-calorie diet, refined carbohydrates, and diets high in polyunsaturated fatty acids •Take high dietary fiber •Avoid weight-reduction diets with severe caloric restriction l
