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CHIEF COMPLAINT: Abdominal pain.

HISTORY OF PRESENT ILLNESS: This is a 24-year-old female who presents with the onset last evening of
fairly intense right upper quadrant abdominal pain, with radiation to the back, which has persisted all night and
in to today. She has had a lot of nausea, but no actual vomiting. She has not had a bowel movement for 48
hours, and she has had no history of diarrhea, constipation, hematemesis, hematochezia, or melena. The pain is
worse when she moves around. She had also been complaining of right lower quadrant abdominal pain. She
has undergone a fairly extensive workup, including laboratory work, which was essentially within normal
limits. She has had a CT scan, which showed a lot of stool in the right colon, but no evidence of acute
appendicitis, and possibly a small right ovarian cyst. An ultrasound was normal, without stones, and a HIDA
scan has been done and showed a 19% ejection fraction, and she had reproduction of her pain and intensification
of her pain when the medication was given.

PAST MEDICAL HISTORY: Allergies: Monistat. Current Medications: None. Surgeries: Tonsillectomy.
Illnesses: No serious illnesses.

FAMILY HISTORY: The patient has several close family members with gallbladder disease. Otherwise, the
patient’s family history is unremarkable.

SOCIAL HISTORY: The patient is married, has two children. She denies the use of alcohol and tobacco.

PHYSICAL EXAMINATION: General: The patient is a fairly thin, alert, oriented, and cooperative female,
who appears to be in mild to moderate distress. Head: The head is atraumatic and normocephalic. Eyes:
Extraocular movements are intact. The pupils are equal, round, and reactive. Ears: The ears are clear bilaterally.
Nose: The nares are patent without discharge. Mouth: The mouth is without lesions, erythema, or exudate.
Neck: The neck is supple without thryomegaly or adenopathy. Lungs: The lungs are clear to auscultation and
percussion. Heart: The heart reveals a regular rate and rhythm, without murmurs, rubs or gallops. Abdomen:
The abdomen is soft. She is tender all along the right side, with a little bit of increased tenderness in the right
lower quadrant at McBurney’s point, with tenderness in the right subcostal area, with positive Murphy’s sign.
No definite organomegaly, masses, or hernias are appreciated. No actual peritoneal signs are identified.
Extremities: The extremities reveal no cyanosis, clubbing, or edema. Neurologic: The neurologic examination
is grossly intact.

IMPRESSION: Right upper quadrant abdominal pain, chronic cholecystitis, with biliary dyskinesia.

RECOMMENDATION: The plan is to give the patient an enema to see if we can resolve her right lower
quadrant or right upper quadrant abdominal pain. If her right upper quadrant abdominal pain persists, then I
would recommend that we proceed with a laparoscopic cholecystectomy with cholangiograms. I have explained
the operation to the patient, along with the risks, and the possibility of an open laparotomy. The patient wishes
to proceed with surgery as outlined above, if the enema does not seem to solve her problem.