Identifying Data:
26YOF
Date & Time of Encounter: 10/14/24 1430
Chief Complaint: RUQ pain x 4 days
HPI:
26YOF G4P1 w/ no PMH, s/p CSD x1 (2023); presents c/o RUQ pain x 4 days. Pt reports constant, non-radiating RUQ “pressure” with intermittent sharp pain that is provoked by eating. Pt states pain is 9/10 severity at worst but 7/10 at time of this interview. Pt is also reporting constipation and more frequent belching since onset of symptoms. She notes h/o constipation and reports taking psyllium at home without relief. She is able to pass gas normally and reports normal appetite, last oral intake was lunch today at about 2pm. Denies N/V/D, blood in stool, fever, urinary symptoms, CP, SOB. LMP 9/29/24. Endorses positive family history of gallbladder disease, states her mother is s/p cholecystectomy.
Past Medical History:
Present illnesses – Denies
Past medical illnesses – Denies
Childhood illnesses – Denies
Immunizations – Up to date, including annual covid and flu
Screening tests and results – Last annual 4/2024. G4P1, Pt sees gyn for routine pap screenings.
Past Surgical History:
CSD 2023, uncomplicated
Past injuries or transfusions
Denies
Medications:
Denies
Allergies:
Denies
Family History:
Father: alive, HTN and DMT2
Mother: alive, s/p cholecystectomy
Denies known family history of cancer
Social History:
Pt is married and lives with her husband and child. She works as a school teacher.
She is a non-smoker. Reports alcohol intake socially, ~1-2 drinks per week.
Denies recent travel.
Reports a well-balanced diet with daily fruits and vegetables.
Reports moderately active lifestyle, exercising at least 30 minutes 3-4 days/week
Reports sexual activity with her husband only.
ROS:
- General/Constitutional:
- Denies fever, diminished appetite, fatigue.
- HEENT:
- Denies ear pain, sinus congestion, sore throat.
- Respiratory:
- Denies wheezing, cough, sputum, shortness of breath.
- Genitourinary:
- Denies painful urination, frequent urination, abnormal discharge.
- Gastrointestinal:
- Reports RUQ abdominal pain, frequent belching, and constipation. Denies diarrhea, nausea, vomiting.
- Skin:
- Denies pain, warmth, erythema.
- Cardiovascular:
- Denies chest pain, dyspnea on exertion, palpitations.
- Musculoskeletal:
- Denies arthralgias, myalgias, back pain.
- Neurologic:
- Denies dizziness, headache.
- Psychiatric:
- Denies anxiety or depressed mood.
Physical:
Vitals:
Temp: 98.0
HR: 95bpm
Oxygen sat %: 99% RA
RR: 16
Ht: 5ft 3in,
Wt: 138
BP: 102/70
Pain scale: 7/10
BMI: 24.44
General:
Well-nourished, neatly groomed hispanic female, A&Ox4, that looks younger than her stated age, dressed appropriately for the weather. Pt appears slightly uncomfortable laying on her side in the ED bed.
Skin, Hair and Nails:
Skin is warm & moist, good turgor. No jaundice. No visible tattoos or markings.
Eyes:
Symmetrical OU. No strabismus, exophthalmos or ptosis. Sclera white and non-icteric, cornea clear, conjunctiva pink.
Nose:
Symmetrical with no masses, lesions, deformities, or trauma.
Neck:
Trachea midline. No masses, lesions, scars, or visible pulsations noted.
Lungs:
CTA B/L, no adventitious breath sounds
Heart:
Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.
Abdomen:
Slightly distended, but soft. RUQ tender to palpation, Murphy’s sign is positive. Abdomen is otherwise nontender, no guarding or rebound noted. One well-healed horizontal surgical scar across the lower abdomen. Bowel sounds normoactive in all four quadrants. No striae or pulsations noted. No hepatosplenomegaly or CVA tenderness.
Assessment
26YOF G4P1 s/p CSD x1 (2023); presents c/o RUQ pain and constipation x 4 days. Pain is provoked by eating, Murphy’s sign is positive on exam; I suspect biliary tree disease. Pt endorses h/o chronic constipation, no LLQ tenderness on exam, so lower suspicion for SBO or diverticulitis. Pregnancy test negative, no lower abdominal/suprapubic tenderness, so low suspicion for gyn pathologies.
DDx:
- Cholelithiasis/Cholecystitis
- Duodenal ulcers
- Hepatitis
- Bloating
- SBO
Plan
-CBC
-CMP
-Lipase
-UA
-Urine HcG
-RUQ U/S
