Home » Clinical Course Work » Rotation 1 – QHC Surgery » History and Physical Write-Up – Cholelithiasis with Fitz-Hugh Curtis

History and Physical Write-Up – Cholelithiasis with Fitz-Hugh Curtis

H&P with Preceptor Comments: Rotation 1 – H&P3

IDENTIFICATION: January 17, 2018, 9:00AM

AA, F, Hispanic, American, 78 years old, married, 789 Peel Street, Queens, NY 13887, Catholic.

INFORMANT: The patient herself is a reliable historian.

REFERRAL SOURCE: Self

CHIEF COMPLAINT: “Right Sided Abdominal Pain x 3 months”

PRESENT ILLNESS: GF is a 78 year old female, with a PMH of HTN, HLD, DM, asthma, kidney stones, PID and depression, presents to QHC, with prior diagnosis of gallstones (10/2018) and a 3 month history of intermittent upper right sided abdominal pain, for a cholecystectomy. Patient notes her pain is associated with eating cheese and reports intermittent nausea and vomiting associated with episodes of abdominal pain. Patient denies chest pain, difficulty breathing, shortness of breath, headaches and backaches.

Of note, patient was hospitalized in October 2018 for gallstone pancreatitis. Patient had an EGD 11/26/19 was recommended for a cholecystectomy following the pathology report, prompting her subsequent visit today. 

PAST MEDICAL HISTORY

  • HLD
  • Vitamin D deficiency
  • DM II
  • Mild persistent asthma
  • HTN
  • Osteoarthritis
  • Recurrent nephrolithiasis
  • PID
  • Breast mass
  • Depression

 PAST SURGICAL HISTORY

  • Spine Surgery – Cervical 2017, Lumbar x2 2018
  • Bilateral lumpectomies
  • Vaginal Hysterectomy
  • Transoral EGD 11/2018

MEDICATIONS

  • Amlodipine, 5mg PO
  • ASA, 81 mg PO
  • Ramipril, 1.25 mg PO
  • Insulin, PRN

ALLERGIES

  • Penicillin, rash
  • Percocet, hallucinations
  • Sulfa, rash
  • Simvastatin, hives
  • No food/environmental allergies

FAMILY HISTORY

  • Paternal Grandfather – deceased, colon cancer
  • Mother, deceased – HTN, DM
  • Father, deceased – HTN
  • Sister, alive 69 – breast cancer
  • Brother, alive 74 – DM
  • 3 children – alive and well

SOCIAL HISTORY

  • Reports social EtOH
  • Denies smoking and illicit drug use
  • Patient is no longer sexually active
  • Patient is retired

REVIEW OF SYSTEMS

General: denies any recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, night sweats.

Skin, hair and nails: Breast, abdominal & back scar noted. Patient denies and chances in texture, excessive dryness or sweating, moles/rashes, pruritus or changes in hair distribution.

Head: Patient denies headache, vertigo, light-headedness or head trauma.

Eyes: Patient denies visual disturbances, blurring, diplopia, fatigue with use of eyes, scotoma, halos, lacrimation, photophobia or pruritus. Last eye exam unknown. Patient does not wear glasses.

Ears: Patient denies deafness, pain, discharge, tinnitus. Patient does not wear hearing aids.

Nose/Sinuses: Patient denies discharge, epistaxis, obstruction.

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat, mouth ulcers or voice changes. Patient does not wear dentures. Last dental exam unknown.

Neck: Patient denies localized swelling/lumps or stiffness/decreased range of motion.

Breast: Patient denies lumps, nipple discharge or pain. Last mammogram 7/2018.

Pulmonary System: Patient denies dyspnea (SOB), dyspnea on exertion (DOE), cough, hemoptysis, cyanosis, orthopnea or paroxysmal nocturnal dyspnea (PND).

Cardiovascular System: Patient reports HTN, as per HPI. Patient denies chest pain, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur.

Gastrointestinal System: Patient reports abdominal pain, change in bowel habits, nausea, vomiting, intolerance to specific foods and changes in appetite as per HPIT. Patient denies constipation, dysphagia, pyrosis, flatulence, eructations (belching, burping), diarrhea, jaundice, hemorrhoids, rectal bleeding or blood in stool.

Genitourinary System: Patient denies urinary frequency, nocturia, urgency, oliguria, polyuria, dysuria, discoloration of urine, incontinence, awakening at night to urinate or flank pain.

  1. Sexual History
    • Patient is not sexually active.

Menstrual and Obstetrical

  • Date of last normal period – unknown
  • Menarche – age 13
  • Patient denies vaginal discharge, dyspareunia.
  • Menopause
  • Date of cessation – May 1991
  • Associated symptoms – unknown
  • Break through bleeding – denied
  • G3, P3 (1203)

Nervous System: Patient denies seizures, headache, loss of consciousness, sensory disturbances, numbness, parethesias, dysesthesias, hyperesthesias, ataxia, loss of strength, change in cognition / mental status / memory or weakness.

 Musculoskeletal System: Patient denies any muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral Vascular System: Patient denies intermittent claudication, coldness or trophic changes, varicose veins, color change or peripheral edema.

Hematologic System: Patient denies history of PE, anemia, easy bruising or bleeding, lymph node enlargement. Patient denies blood transfusions.

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter, excessive sweating.

Psychiatric: Patient reports depression. Patient denies sadness, feelings of helplessness, feelings of hopelessness, lack of interest in usual activities, suicidal ideations, anxiety, obsessive / compulsive disorder. Patient has seen a mental health professional.

GENERAL SURVEY: 78-year-old female A/O x3. Patient appears to be of stated age and well nourished. Patient is in no acute distress.

VITALS

BP: 153/66 mmHg, supine, right arm

R: 18 breaths / min, unlabored

P: 99 beats / min, regular rhythm

SpO2: 98% on RA

Temperature: 98 F (oral)

Height: 4’11’’                            Weight: 145 lbs                                                            BMI: 29.2

PHYSICAL EXAM

SKIN: Warm & dry, good turgor. Breast, abdominal & back scar noted. Nonicteric, no lesions noted, no tattoos.

HAIR: Average quantity & distribution.

NAILS: No clubbing, capillary refill <2 seconds throughout.

HEAD: NC/AT nontender to palpation throughout.

EYES: No conjunctival injection, bilaterally. Symmetrical OU; no evidence of strabismus, exophthalmos or ptsosis; sclera white; cornea clear. Visual acuity: 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU. PERRLA. EOMI with no nystagmus. Fundoscopy – red reflex intact OU. Cup: disc </= 0.5 OU. No evidence of AV nicking, papilledema, hemorrhage, exudate, cotton wool spots, neovascularization OU.

EARS: Symmetrical & normal size. No evidence of lesions, masses, trauma on external ears. No discharge or foreign bodies in external auditory canals AU. TMs pearly white, intact with light reflex in normal position AU. Auditory acuity intact to whispered voice AU. Weber midline / Rinne reveals AC > BC AU.

NOSE: Symmetrical, no obvious masses, lesions, deformities, trauma, discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions, deformities, injection or perforation. No evidence of foreign body.

SINUSES: Nontender to palpitation and percussion over bilateral frontal, ethmoid & maxillary sinuses.

LIPS: pink, moist, no evidence of cyanosis or lesions.

MUCOSA: Pink, well hydrated. No masses; lesions noted, No evidence of leukoplakia.

PALATE: Pink, well hydrated. Intact with no masses, lesions or scars.

TEETH: Good dentition, with no discoloration of teeth.

GINGIVAE: Pink, moist. No evidence of hyperplasia, masses, lesions, erythema or discharge.

TONGUE: Pink, well papillated, no masses, lesions or deviations noted. Oropharynx well hydrated, no evidence of injection, exudates, masses, lesions, foreign bodies. Tonsils present with no evidence of injection or exudates. Uvula pink, no edema, lesions.

NECK: Trachea midline, no masses, lesions, scars, pulsations noted. Supple, nontender to palpation. Full ROM, no stridor noted, 2+ carotid pulses bilaterally, no thrills bilaterally, no bruits noted bilaterally, no palpable adenopathy noted.

THYROID: Non-tender, no palpable masses, no thyromegaly, no bruits noted.

CHEST: Symmetrical, no deformities, no evidence of trauma.   Respirations unlabored no paradoxic respirations or use of accessory muscles noted. LAT to AP diameter 2:1. Nontender to palpation.

LUNGS: Clear to auscultations & percussion bilaterally. Chest expansion & diaphragmatic excusions symmetrical. Tactile fremitus intact throughout. No wheezing, rhonci, crackle, rales noted.

HEART: JVP is ~2.0cm above sternal angle with head at ~30 degrees. PMI is in 5th ICS in midclavicular line. Carotid pulses 2+ bilaterally without bruit. RRR. S1 & S2 normal. No murmurs or gallops noted.

ABDOMEN: Soft, mildly distended. Mild tenderness, no guarding. No rigidity. BS normal. Obturator, Psoas, Rovsing signs negative. 6 cm lower abdominal scar noted.

GENITALIA: Patient declined.

RECTAL: Patient declined.

VASCULAR: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.

NEURO: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted.

MUSCULOSKELETAL: No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.

DIAGNOSTICS:

  1. LABS:
    • WBC: 7.21 (normal)
    • Hgb: 13.3 (normal)
    • Hgb A1C: 8.4 (high)
    • Hct: 40.4 % (normal)
    • MCV: 89.8 (normal)
    • PLT: 270 (normal)
    • PLT Morphology: normal
    • Creat: 0.88 (normal)
    • BUN: 21 (normal)
    • SODIUM: 137 (normal)
    • POTASSIUM: 4.6 (normal)
    • CHLORIDE: 102 (normal)
    • CO2: 23 (normal)
    • GGT: 46 (high)
    • AlkPhos: 108 (high)
    • Total Bilirubin: 0.9 (normal)
    • Direct Biliribin: 0.4 (high)
    • APTT: 30 (normal)
    • LIPASE: 49 (normal)
  2. IMAGING:
    • Abdominal US: Common duct is not dilated. No stones in common duct can be seen. Gallstones noted.
    • MRI Cholangiography: Acute cholecystitis with a large gallstone noted within the gallbladder. No evidence of choledocholithiasis.

ASSESSMENT: 78 year old female, with a PMH of HTN, HLD, DM, asthma, kidney stones, PID and depression, presents to QHC for cholecystectomy following laboratory and US diagnosis of gallstone pancreatitis.

PLAN:

  1. Cholelithiasis
    1. Proceed with laparoscopic cholecystectomy as planned
    2. Patient NPO
    3. IV Fluids
      1. NS 1000 mL bolus
    4. Prophylactic IV Antibiotics
      1. Clindamycin 900mg
    5. Pain Control
      1. Ketorolac 40mg
    6. Hypertension
      1. Continue with medication as prescribed
        1. Ramipril, 1.25 mg PO
        2. Amlodipine, 5mg PO
      2. Continue to monitor
    7. Diabetes Mellitus
      1. Continue with medication as prescribed
        1. Insulin PRN
      2. Follow up with endocrinologist for elevated A1C
    8. Hyperlipidemia
      1. Continue with medication as prescribed
        1. ASA 81 mg PO
      2. Depression
        1. Follow up with PCP
      3. Asthma
        1. Follow up with PCP

DDx:

  1. Cholecystitis
  2. Cholelithiasis
  3. Choledocolithiasis
  4. Pancreatitis
  5. Costochondritis

 

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