DATE OF OPERATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who was brought into the hospital with a complaint of abdominal pain associated with tenderness. The patient stated that he has been experiencing abdominal pain in the upper part of the abdomen associated with significant bloating. The patient denies any nausea, vomiting, diarrhea, constipation, fever or chills.
PAST MEDICAL HISTORY: No past medical history.
PAST SURGICAL HISTORY: Significant for appendectomy.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: Significant for four cigarettes of smoking per day, and the patient drinks over the weekend.
PHYSICAL EXAMINATION: At the time of evaluation, the patient was found to have a temperature of 98 degrees, pulse of 84, and blood pressure of 108/60. Focal abdominal examination of the patient revealed a soft, nontender, and nondistended abdomen.
LABORATORY DATA: Revealed white cell count of 12,200, hemoglobin of 12.4, hematocrit of 36, and platelet count of 244,000. Chemistry profile reveals sodium 142, potassium 4.4, chloride 108, CO2 of 26, glucose 118, BUN 8, creatinine 1, calcium 9.2, bilirubin 0.5, alkaline phosphatase of 122, ALT 32, AST 16, cholesterol 180, and triglycerides 260.
RADIOLOGICAL DATA: These include chest PA and lateral. Chest x-ray shows irregular costochondral junction of rib #5 on the right. This could be consistent with osteochondritis. CT abdomen and pelvis reveal questionable diverticulitis of the proximal left colon and a small rib lesion on the right, inferiorly, possibly representing osteochondroma. HIDA scan of the hepatobiliary system reveals normal hepatobiliary scan with low ejection fraction of the gallbladder of about 11% at 30 minutes. CT scan of the chest reveals a small lung nodule, right middle lobe, for which follow up in six months was suggested. Also, there was a lesion involving the right fifth rib measuring 2.2 x 3.3 cm, could be enchondroma.
ASSESSMENT AND PLAN: This is a (XX)-year-old gentleman with symptoms of abdominal pain associated with tenderness and bloating. Currently, the patient has no tenderness on physical examination. He is afebrile, hemodynamically stable, and is tolerating his diet. The patient does have dysfunctional gallbladder and requires gallbladder removal that is cholecystectomy. We can bring this patient back into the hospital as the same day admission surgery patient for elective cholecystectomy. We have counseled the patient in detail to come and see us in the office next week for his gallbladder surgery.
Thank you, Dr. Doe, for allowing us to participate in the care of this patient.
