RT 1 – Surgery

S: 

51 y/o F, with no PMHx, who presents to the surgery clinic for evaluation after being seen in the ED on 2/10/21 for RUQ abdominal pain x 3 days with associated nausea. Patient was diagnosed with cholecystitis secondary to cholelithiasis and discharged home with Ciprofloxacin and Metronidazole. Per family member, the patient was not taking her antibiotic correctly, but patient reports she is now taking it as prescribed. Patient reports intermittent abdominal pain associated with fatty meals and states her last episode of pain was three days ago. She was also seen in another ED on 2/8/21 for similar symptoms. She denies any current abdominal pain, nausea, vomiting, decreased appetite, change in bowel habits, fever or chills. Patient reports she had T wave inversions on her EKG in the ED last week and went to her cardiologist for follow up. She states she has an echo and stress test scheduled in the upcoming weeks. 

PMHx: none 

PSHx: none 

Medications: Aspirin 81mg PO once daily

Allergies: NKDA 

Social history: Denies smoking, drinking or drug use 

O:

Vitals: T 98.9 F, HR 78 bpm, RR 16 breaths per minute, BP 102/69, Wt 153 lb, BMI 25.46, O2 99% on room air 

Physical Exam:

General: alert and oriented, in no acute distress 

Skin: no jaundice

HEENT: no gross abnormalities, no scleral icterus 

Abd: soft, nontender, nondistended, negative Murphy’s sign, bowel sounds present in all four quadrants

A:

51 y/o F, with no PMHx, who presents to the clinic for evaluation after being diagnosed with cholecystitis on US in the ED last week.

P:

Continue to take antibiotics that were prescribed in the ED

Follow up as scheduled with cardiology for clearance

Return to the clinic in 6 weeks for re-evaluation and scheduling for elective cholecystectomy