Cholelithiasis SOAP note Spring Arbor University Brett Locke
Name: S.S. Date : 11/21/2019 Time : 0845
DOB: 6/4/1997 Sex: Female
Subjective
CC: RUQ abdominal pain and gallstones
HPI: Mrs. Snyder is a pleasant 2
...
Cholelithiasis SOAP note Spring Arbor University Brett Locke
Name: S.S. Date : 11/21/2019 Time : 0845
DOB: 6/4/1997 Sex: Female
Subjective
CC: RUQ abdominal pain and gallstones
HPI: Mrs. Snyder is a pleasant 22-year-old female who presents to the office today for evaluation of right upper quadrant abdominal pain that has been present intermittently for roughly one year. Her symptoms have progressively gotten worse over the past 4 weeks. She complains of intermittent, sharp/stabbing, right upper quadrant abdominal pain that can occur after any meal, but particularly after foods that are high in fats. The pain typically lasts about 2 hours. She reports nausea and vomiting when she is having pain. She denies diarrhea, constipation, fever, chills or night sweats. She rates her pain at 7/10 when at its worst. She was evaluated in the emergency department on 11/15/19 as her pain was not improving. She underwent a right upper quadrant ultrasound while in the ED that demonstrated cholelithiasis with multiple prominent mobile shadowing gallstones. There was no evidence of cholecystitis. Her common bile duct measured 5-6 mm by ultrasound. Her AST was elevated at 433, ALT at
396. LDH was not performed at that time however, this was drawn in July and was elevated at
268. A lipase was obtained while at the ED which returned at 143. An amylase was not performed.
Medications:
ProAir HFA 108 (90 base) mcg/ACT aerosol solution, 2 puffs q 6 hours prn
Albuterol Sulfate (2.5 mg/3 ml) 0.083% nebulization, 3 ml inhalation per nebulizer q 8 hours prn
Advair Diskus 100-50 mcg/dose aerosol powder breath activated, 1 puff inhalation BID Venlafaxine 150 mg, 1 tablet with food by mouth once daily
Allergies:
Amoxicillin – reaction: hives
PMI
Illnesses/Injuries Childhood – Varicella
Adult – Asthma, Depression Hospitalizations/Surgeries:
Oral extraction, wisdom teeth, 2013 Vaccinations
Influenza – 11/1/19 Pneumovax – n/a Tetanus – 1/2018 HPV – completed a 3-dose series: 2/2015, 4/2015, 8/2015
Health Maintenance:
Last mammogram – n/a, not indicated at this time. Begin screening per protocol
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