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DATE OF ADMISSION: 05/03/2017

PRIMARY CARE PHYSICIAN: Clinic Ole.

CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female with past medical history
of depression and migraine headaches, who was in her usual state of health until approximately
the day of admission, at around 12:15 pm, when she started developing superior epigastric pain
radiating to her back that was intermittent in nature, lasting anywhere from 15 to 30 minutes at a
time, several times an hour, and the pain was very strong 7-10/10, sharp in nature; also going up
to the right upper quadrant to back. She denies any associated symptoms, including shortness of
breath, dizziness, lightheadedness, syncope, nausea, vomiting, and diaphoresis. She was
brought into the ER for a bedside ultrasound by the ER physician, Dr. Lopez, which showed
gallstone. Formal ultrasound showed a gallbladder containing a large gallstone with tenderness
suggestive of cholecystitis, and she was then admitted for further workup. She also had an
elevated lipase, suggestive of pancreatitis and gallstone pancreatitis.

PAST MEDICAL HISTORY: As per above.

PAST SURGICAL HISTORY: She has had:


1. Prior C-section.
2. Right clavicle surgery.

FAMILY HISTORY: Mother had hypertension and depression. Father had MI.

SOCIAL HISTORY: No smoking, alcohol, or IV drug abuse. Lives in Napa Valley


with her husband. She does not work.

REVIEW OF SYSTEMS: All systems reviewed and negative except as per HPI. All
other pertinent positives and negatives were reviewed.

MEDICATIONS: At home include:


1. Ibuprofen.
2. Paroxetine for depression.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4 degrees Fahrenheit. Pulse 72. Respiratory rate 18. Blood
pressure 129/74. O2 sats 99% on room air.
GENERAL: Alert.
HEENT: PERRLA.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, mildly tender to palpation in the superior epigastric region of
right upper quadrant region. No guarding. No rebound. Normoactive bowel
sounds. No hepatosplenomegaly.
MUSCULOSKELETAL: No clubbing, cyanosis, or edema.
NEURO: No focal deficits.

LABORATORY DATA: White count 15.1, hemoglobin 14.4, platelets 243.

Sodium 138, potassium 3.5, bicarb 23, creatinine 0.5, glucose 149. ALT and AST 50, alkaline
phosphatase 129, total bilirubin was normal at 1.1, lipase is 367.

Gallbladder ultrasound: Showed as per the above.


ASSESSMENT AND PLAN: The patient is a 50-year-old female, admitted for:
1. Acute gallstone pancreatitis with leukocytosis: We will continue on Zosyn
and keep her n.p.o. Continue IV fluids, IV PPI. General Surgery and
Gastroenterology have been consulted for cholecystectomy and ERCP
evaluation during this hospital stay. We will continue pain control with
morphine.
2. History of depression: Continue paroxetine once stable.
3. History of migraines: Resume ibuprofen once stable.
4. Deep venous thrombosis prophylaxis: With Lovenox.
5. Gastrointestinal prophylaxis: With Protonix.
6. CODE STATUS: FULL.

The patient's case was discussed with the translator over the video screen, as
well as the patient's husband, and the ER physician Dr. Nicholas Lopez.