DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abnormal liver enzymes, gallstones, rule out common duct stones.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who has a history of diabetes and marked exogenous obesity, who came to the hospital because of pain in the right upper quadrant area, which was moderate to severe in intensity. The patient was admitted, and cardiac workup was undertaken and it was negative. The patient underwent GB sonogram, which showed gallstones. Because there was a question of abnormality on the echocardiogram and stress test, the patient was transferred to this hospital for further cardiac workup; however, it was thought that most of the symptoms were secondary to gallstone rather than cardiac in nature. The patient was seen by Dr. John Doe who has already evaluated the patient. The patient’s bilirubin was found to be 3.0 with alkaline phosphatase 192, and GI consultation has been requested by Dr. Doe to further evaluate with ERCP if common duct stone was found on MRCP, which has already been ordered. Presently, the patient is asymptomatic.
PAST MEDICAL HISTORY:
1. History of massive upper GI bleeding 8 years ago, which required laparotomy and the patient was found to have bleeding from the esophageal tear.
2. Diabetes type 2.
3. Exogenous obesity.
4. Hyperlipidemia.
SOCIAL HISTORY: The patient does not smoke or drink.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Other than history of present illness nothing significant. The patient does have difficulty ambulating and is short of breath on mild exertion. No chest pain, no cough, expectoration or hemoptysis. No chills or fever.
PHYSICAL EXAMINATION:
GENERAL: Revealed a well-built, well-nourished female who was sitting up beside her bed, does not seem to be in any distress or short of breath. She is asymptomatic at this time.
VITAL SIGNS: Temperature is 97.6 degrees, pulse is 94, and blood pressure is 142/78.
HEENT: Examination is unremarkable.
NECK: JVP is not raised.
HEART: Both heart sounds are audible.
LUNGS: Clear to percussion and auscultation.
ABDOMEN: Distended and obese but is nontender. Liver and spleen are not enlarged or palpable.
EXTREMITIES: No pedal edema in the feet.
NEUROLOGIC: Examination is normal.
LABORATORY DATA: Hemoglobin 13.8, hematocrit 41.2, and platelet count is 298,000. Electrolytes are normal. Glucose is 210, BUN is 9, and creatinine 0.9. Liver enzyme shows total bilirubin is 2.3, alkaline phosphatase 190, ALT 108, and AST 102.
IMPRESSION:
1. Right upper quadrant abdominal pain, abnormal liver enzymes with elevated bilirubin and alkaline phosphatase, gallstone. Rule out common duct stone.
2. Diabetes.
3. Hyperlipidemia.
4. Exogenous obesity.
RECOMMENDATIONS: We agree with the management and plan and MRCP. If MRCP shows dilated common bile duct and/or filling defects in the common bile duct, then certainly take an ERCP before cholecystectomy.
