DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Epigastric pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a week of epigastric and right upper quadrant pain, getting worse, somewhat short of breath, which can worsen with exertion. The pain is in the lower anterior chest. It can worsen with exertion. He feels bloated. His appetite is down. He feels sick when he eats. The patient has a history of asthma. He was seen in the ER two days back. White count at that time was 12,400. Chest x-ray, EKG, troponins, CK-MB, amylase, lipase, and liver panel were normal.
We saw the patient the day prior to admission and started him on Protonix, which did not help him. He complains of nausea without vomiting. No fever. CBC the day prior to admission showed a white count of 12,600. Amylase, lipase, and liver panel were normal, except minimal ALT elevation at 48. His chronic medical problems include chronic pain with reflex sympathetic dystrophy, mood disorders including panic, hypertension, proteinuria, hypogonadism, restless legs syndrome, and erectile dysfunction.
PAST MEDICAL HISTORY: Vasectomy, heel and ankle surgery, and severe headaches.
MEDICATIONS: Duragesic 25 mcg patch every 3 days, Catapres-TTS-2 patch every 7 days, methadone 10 mg every 8 hours as needed for breakthrough pain, Bextra 20 mg daily, Seroquel 50 mg nightly as needed for sleep, Wellbutrin XR 300 mg daily, Tegretol 200 mg nightly, Cialis 20 mg p.r.n., AndroGel 5 mg daily, and Klonopin 1 mg nightly.
ALLERGIES: NKDA.
FAMILY HISTORY: Heart disease, diabetes, and coronary artery disease.
SOCIAL HISTORY: The patient is divorced, and he is a nonsmoker and nondrinker. He is disabled.
REVIEW OF SYSTEMS: Negative.
PHYSICAL EXAMINATION: Vital signs revealed a blood pressure of 128/86, temperature 98.6, pulse 74, respirations 18, and weight 195. He was mildly ill. HEENT examination was negative. Neck was supple without jugular venous distention, thyromegaly, adenopathy or bruits. Carotid pulses were 2+ and equal. Lungs were clear. Heart was without murmurs, gallops or rubs. Abdomen was soft, moderately tender in the epigastrium and right upper quadrant with rebound, worse compared to the day prior to admission. No hepatosplenomegaly. Extremities had no clubbing, cyanosis or edema. Distal pulses were 2+ and equal. Neurologic examination was grossly normal.
EKG is normal.
HOSPITAL COURSE: The patient was admitted with a diagnosis of acute cholecystitis, had to rule out MI, but the shortness of breath was likely either from panic or irritation from the cholecystitis. He was cultured, put on Levaquin and Flagyl. Ultrasound of the abdomen was normal. HIDA scan with CCK was normal.
Gastroenterology was consulted. Endoscopy showed minimal disease, nothing that would explain his pain. The day after admission, his white count was higher at 13,400 with a left shift. The patient continued to have pain in the right upper quadrant. Because his history and physical and white count were consistent with acute cholecystitis, he had a cholecystectomy despite the normal test. The patient understood the potential risks and benefits.
Dr. John Doe did the surgery and found an acute cholecystitis. The patient tolerated the procedure well. The next day, he was feeling fine. He had some incisional soreness. Examination was normal. Sodium was slightly high at 147. H&H was low at 13.4/38.4.
FINAL DIAGNOSIS: Acute cholecystitis.
DISCHARGE INSTRUCTIONS: He will go home. Follow up next week with us and subsequently with Dr. John Doe. Activity and diet as tolerated.
DISCHARGE MEDICATIONS: Levaquin 500 mg daily for 3 days, Flagyl 500 mg t.i.d. for 3 days, and preadmission medications as listed above.
