REASON FOR VISIT: Cholelithiasis.
SUBJECTIVE: This is a (XX)-year-old woman who comes in for evaluation of abdominal pain and cholelithiasis. The patient gives a history of a cervical cone biopsy. Her procedure was complicated and required a concomitant or subsequent laparoscopy. Postoperatively, she developed right lower quadrant abdominal pain, which has slowly but steadily resolved. This was accompanied by some nausea and vomiting. The bulk of abdominal pain and vomiting has resolved; however, she has still has a little bit of nausea. She indicates that the nausea is substantially less than it had been.
The patient denies any history of epigastric and right upper quadrant abdominal pain. No history of back pain or right shoulder pain. She has had no history of jaundice, no history of dark urine or acholic stool. The patient has no particular fatty food intolerance, and eating does not seem to be associated with an exacerbation of her symptoms. She again insists that her abdominal pain has essentially resolved.
During the course of her evaluation, she has had a CAT scan, which demonstrated the presence of gallstones. This finding corroborates abdominal ultrasounds performed prior, which also demonstrated cholelithiasis.
OBJECTIVE: On examination, the patient is a very thin, somewhat anxious-appearing woman who looks approximately her stated age and does not appear to be in any acute distress. Vital signs include a blood pressure of 114/74, a pulse of 86, a height of 64 inches, and weight of 98 pounds. Examination was limited largely to her abdomen, which was scaphoid, soft, and nontender. The patient has no hepatomegaly, no splenomegaly, and no abdominal masses that are discernible. The patient has no direct tenderness, no guarding, no percussion tenderness, and no rebound tenderness. She has well-healed surgical scars consistent with laparoscopy.
ASSESSMENT AND PLAN: It is our impression that the patient has cholelithiasis, which at present appears to be asymptomatic. We counseled her regarding presently asymptomatic cholelithiasis. We discussed the potential presentations of symptoms related to her gallbladder including those, which may be acute and require management and even a visit to the emergency room or even admission to the hospital. The patient indicated that she understood all of this.
We also explained that at present the consensus is that asymptomatic cholelithiasis does not require a cholecystectomy. It is our impression that she has known cholelithiasis, but her current and recent symptoms are unlikely to be related to her cholelithiasis. We indicated to her that she did not need to make a specific followup appointment but certainly should call should she develop symptoms.
