Clinical note · #65
Procedures & modifiers
DOS 01/01/2025: Office visit: severe right upper abdominal pain
Patient: Sarah Wilson · MRN: 20098765 · Age / gender: 35 / female
Chief complaint
Severe right upper abdominal pain with nausea and vomiting for 12 hours.
History of present illness
Patient presents with sudden onset of sharp right upper quadrant pain radiating to the back and right shoulder. Associated nausea and two episodes of vomiting. Denies chest pain or urinary symptoms. Reports similar but milder episodes in the past that resolved without treatment.
Review of systems
Positive for abdominal pain, nausea, and vomiting. Negative for fever, chills, chest pain, shortness of breath, or urinary complaints.
Past medical, family, social history
No chronic medical conditions. No known drug allergies. Family history significant for gallstones in mother. Non-smoker, occasional alcohol use.
Physical exam
Vitals: BP 128/80 mmHg, HR 96 bpm, Temp 99.5°F, RR 18/min, SpO₂ 98% RA. General: patient in moderate distress due to abdominal pain. Abdomen: right upper quadrant tenderness with positive Murphy's sign. No rebound tenderness or guarding. Bowel sounds present. Other systems: heart, lungs, and neuro exam normal.
Diagnostics
Labs: CBC shows mild leukocytosis. Liver function tests mildly elevated. Ultrasound abdomen: thickened gallbladder wall with gallstones and pericholecystic fluid, consistent with acute cholecystitis.
Assessment and plan
Assessment: acute calculous cholecystitis.
Plan: begin oral antibiotics and pain management. Schedule laparoscopic cholecystectomy for 07-Jan-2025 after stabilization of acute inflammation. Patient counseled on diagnosis, procedure, risks, and alternatives. Informed consent obtained for planned surgery. Follow-up instructions provided for worsening symptoms prior to scheduled surgery.
DOS 01/07/2025: Preoperative evaluation & laparoscopic cholecystectomy
Patient: Sarah Wilson · Date: 07-Jan-2025 · Age / gender: 35 / female
Chief complaint
Follow-up for gallbladder surgery (scheduled today).
History of present illness
Patient returns for preoperative evaluation prior to laparoscopic cholecystectomy. She reports that abdominal pain has lessened since antibiotic therapy but still has intermittent right upper quadrant discomfort. Denies fever, chills, vomiting, or jaundice since last visit. She has been following a low-fat diet and tolerating oral intake.
Review of systems
Constitutional: no fever, chills, or weight loss. GI: intermittent RUQ pain, no nausea or vomiting. Cardiac/resp: no chest pain, palpitations, dyspnea. GU: no urinary symptoms. Neuro: no weakness, dizziness, or focal deficits.
Past medical, family, social history
No chronic medical illnesses. No drug allergies. Family history: gallstones (mother). Social history: non-smoker, occasional alcohol use.
Physical exam
Vitals: BP 122/78 mmHg, HR 82 bpm, Temp 98.6°F, RR 16/min, SpO₂ 99% RA. General: patient alert, no acute distress. Abdomen: mild right upper quadrant tenderness, no guarding or rebound. No palpable mass. Heart/lungs: normal heart sounds, clear lungs. Extremities: no edema, normal peripheral pulses. Neuro: alert and oriented, grossly intact.
Preoperative diagnostics
CBC, CMP, coagulation profile within normal limits. Ultrasound findings from prior visit reviewed.
Assessment and plan
Assessment: acute calculous cholecystitis, improved with medical therapy, for definitive surgical management today.
Plan: proceed with laparoscopic cholecystectomy as scheduled. Surgical and anesthesia consents confirmed.
Procedure performed
Laparoscopic cholecystectomy. Under general anesthesia, the abdomen was prepped and draped sterilely. Four laparoscopic ports were placed. The gallbladder was visualized and found to be inflamed but intact. The cystic duct and artery were carefully identified, clipped, and divided. The gallbladder was dissected from the liver bed using electrocautery and removed via the umbilical port. Hemostasis was secured. Ports were closed in layers. Estimated blood loss less than 20 mL. No intraoperative complications.
Intraoperative findings: thickened gallbladder wall with multiple small stones. No perforation, abscess, or bile duct injury observed.
Post-procedure care and plan
Patient tolerated the procedure well. Extubated and transferred to recovery in stable condition. Post-op plan includes oral antibiotics, pain control, early ambulation, and diet advancement as tolerated. Follow-up in surgery clinic in 7 days for wound check.
Attending surgeon: Dr. X, present throughout the procedure.