H&P #2

Identifying Data

Full Name: M.D.

Sex: Female

DOB: xx/xx/1999

Date & Time: October 17, 2023

Location: Metropolitan Hospital

Religion: Unknown

Source of Information: Self

Reliability: Reliable

Source of referral: Self

Mode of transportation: Mass transit

 

Chief Complaint: “abdominal pain” x 2 weeks

 

History of Present Illness:

24 y/o F with no PMHx presents to the ED c/o RUQ abdominal pain x 2 weeks. Patient states pain worsened this morning which prompted her to come to the ED. Describes pain as aching sensation, 8 out of 10 in severity. Pain occasionally radiates to back. Patient has not had a similar pain in the past. States pain typically worsens after meals. Patient endorses nausea x 4 hours with no associated vomiting. Admits to Pepcid use at home with no relief. Denies fever, chills, body aches, jaundice, cough, chest pain, SOB, dizziness, headache, diarrhea, constipation, dysuria, urinary urgency/frequency, sick contacts/recent travel. Patient denies eating a lot of greasy or fatty foods.

Last BM: this morning, regular

LMP: 9/23, regular cycles

 

Differential diagnosis:

  1. Cholelithiasis
  2. Cholecystitis
  3. Pancreatitis
  4. Gastritis
  5. PUD
  6. Pregnancy

 

Past Medical History

Medical History:

  • No past medical history
  • No past hospitalizations or history of blood transfusions.

Medications:

  • No prescription medication use.
  • Denies herbal supplement use.

Surgical History:

  • No past surgical history

Allergies:

  • No known drug/food/environmental allergies

Family History:

  • Mother: Age 52, alive and well.
  • Father: Age 55, alive and well. PMHx HTN, HLD.
  • No known familial cancer hx

Social History:

  • Smoking: Never
  • Alcohol: Socially 1-2x per month
  • Denies past or current illicit drug use
  • Marital History: Single
  • Language: Patient requires Spanish translation
  • Education: High school graduate
  • Occupational History: Waitress
  • Travel: No recent travel
  • Home situation: Lives in Queens apt with mother and sister
  • Sleep: Denies sleep disturbances
  • Exercise: Admits to gym use 1-2 times per week
  • Diet: endorses balanced diet with protein, vegetables and carb
  • Caffeine: denies caffeine use

 

ROS:

  • General: Denies fever, fatigue, chills, night sweats, weight loss, changes in appetite.
  • Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
  • HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies pain, discharge.
  • Pulmonary: Denies cough, dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Denies chest pain, edema/swelling of ankles or feet, palpitations.
  • Gastrointestinal: Admits to abdominal pain x 2 weeks and nausea x 6 hours. Denies vomiting, diarrhea, constipation.
  • Genitourinary: Denies vaginal discharge, dysuria, urgency, frequency, incontinence.
  • Musculoskeletal: Denies muscle pain, joint pain, arthritis, or swelling.
  • Nervous system: Denies headache, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, coldness of extremities, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
  • Endocrine: Denies polydipsia, heat or cold intolerance, excessive sweating.
  • Psychiatric: Denies depression or anxiety.

 

Physical Exam:

Vitals:

  • Weight: 114 lb Height: 63 inches       BMI: 20.4
  • BP: 95/67, right arm sitting
  • RR: 18, unlabored
  • HR: 65, regular
  • Temp: 97.7 F oral
  • SpO2: 100% room air

General: 24-year-old slender female who appears stated age. A/O x 3 and appears in no acute distress, laying comfortably in bed.

HEENT: Normocephalic & atraumatic; PERRLA; EOM intact; Pharynx non-erythematous. No exudates present.

Neck: Trachea midline. Neck supple and non-tender. No lymphadenopathy present.

Heart: Regular rate and rhythm. S1 & S2 distinct with no murmurs or gallops.

Lungs: Clear to auscultation B/L. No adventitious sounds noted.

Abdominal: Abdomen soft, symmetric and non-distended, with no scars. Normoactive bowel sounds in all 4 quadrants. Tenderness to palpation of RUQ with no guarding or rebound Positive Murphy’s sign. Negative CVA tenderness, McBurney’s sign, Rovsing’s sign, psoas sign, obturator sign. No Cullen or grey turner sign noted. No splenomegaly and no hernias noted.

Musculoskeletal: FROM, no cyanosis, no peripheral edema

 

Labs:

CBC –

BMP –

Hepatic panel –

VBG –

HCG – negative

Lipase – 43

 

Imaging:

  • RUQ ultrasound:
    • Liver measures 16.0 cm and is slightly heterogenous without a discrete mass
    • The common bile duct is normal in caliber, measuring 0.57 cm
    • Multiple gallstones are seen within the gallbladder lumen with moderate posterior acoustic shadowing.
    • Sonographic murphy sign is reported to be positive.
    • No gallbladder wall thickening or pericholecystic fluid
    • The pancreatic head and body are unremarkable. The pancreatic tail is obscured by overlying bowel gas.
    • Portal vein grossly within normal limits
    • The right kidney measures 9.83 cm

Impression: cholelithiasis. Sonography murphy’s sign reported to be positive. Correlate for suspected acute cholecystitis.

 

Assessment/Plan:

24 y/o F with no PMHx complaining of worsening abdominal pain x 2 weeks. Pain is associated with nausea but denies any vomiting, fever, chills, diarrhea. Vital signs within normal limits. On exam, RUQ tenderness with positive murphy’s sign. Abdominal ultrasound reveals multiple gallstones within the gallbladder lumen, no GB wall thickening, no pericholecystic fluid and normal CBD.

 

#Abdominal pain

  • NPO for now
  • 1L bolus NS
  • Toradol 15 mg IM for pain
  • Zofran 4 mg IV for nausea
  • Consult general surgery

 

General surgery consult:

  • No indication for acute surgical intervention
  • Trial of clear liquids in ED recommended
  • F/u in outpatient GI clinic on 10/20/23

 

Code status: Full

 

Disposition: Discharge home w/ ER precautions

  • Return to ED if intractable pain, fever, yellow discoloration of skin or eyes, vomiting.
  • Follow up outpatient GI on 10/20/23
  • Follow up with PCP
  • Verbally acknowledges and agrees with plan. All questions answered and concerns addressed.