Clinical note · #50
Hospital & observation
Date: 2024-07-04
Admitting Physician: Dr. Alex Turner, MD
Chief Complaint: Abdominal pain
HPI:
The patient is a 50-year-old male with a 1-day history of severe abdominal pain localized to the right lower quadrant. The pain is constant and aggravated by movement. The patient reports associated nausea and anorexia.
ROS:
- Gastrointestinal: Abdominal pain, nausea, no vomiting.
- Cardiovascular: No chest pain, no palpitations.
- Respiratory: No cough, no dyspnea.
- Neurological: No dizziness, no headaches.
PFSH:
- Past Medical History: Appendectomy, hypertension.
- Family History: No relevant family history.
- Social History: Non-smoker, occasional alcohol use.
Physical Examination:
- Vital Signs: BP 130/85, HR 85, RR 18, Temp 99.1°F.
- Abdomen: Tenderness in the right lower quadrant, rebound tenderness present.
- Cardiovascular: S1, S2 normal.
- Respiratory: Clear to auscultation bilaterally.
MDM:
- Abdominal ultrasound suggests acute cholecystitis.
- WBC count elevated.
- Diagnosis: Acute cholecystitis.
Plan:
- Admit to general surgery.
- Start IV antibiotics.
- Prepare for laparoscopic cholecystectomy.