Sample Name: Admission History & Physical - Nausea
Description: Patient status post gastric bypass surgery, developed nausea and right upper quadrant pain.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Nausea.
PRESENT ILLNESS: The patient is a 28-year-old, who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on it but has not done so. He has overall malaise and a low-grade temperature of 100.3. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.
PAST MEDICAL HISTORY: Significant for hypertension and morbid obesity, now resolved.
PAST SURGICAL HISTORY: Gastric bypass surgery in December 2007.
MEDICATIONS: Multivitamins and calcium.
FAMILY HISTORY: Positive for diabetes mellitus in his father, who is now deceased.
SOCIAL HISTORY: He denies tobacco or alcohol. He has what sounds like a data entry computer job.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION: His temperature is 100.3, blood pressure 129/59, respirations 16, heart rate 84. He is drowsy, but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic, atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular rate and rhythm. His abdomen is soft. He has diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly nonfocal neurologically.
ASSESSMENT: Choledocholithiasis, ? cholecystitis.
PLAN: He will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder out, probably with intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite difficult if not impossible unless laparoscopic assisted. Dr. X will see him later this morning and discuss the plan further. The patient understands.
Keywords: general medicine, gastric bypass surgery, nausea, choledocholithiasis, cholecystitis, ercp, gastric bypass, bypass surgery,