CC: I am scheduled for gall bladder surgery

Subjective:

A 67-year-old male with PMHx HTN, HLD, Arthritis, Cervical Spinal Stenosis, Fatty Liver, Diverticulosis, GERD, History of Kidney Stones, BPH, Environmental and Seasonal Allergies. Patient presents to PAT today prior to scheduled Laparoscopic Cholecystectomy by Dr. Denoto on 10/5/2020. Patient reports “intermittent” right upper quadrant abdominal pain in past 2 months. He describes the pain as cramping, and last about 20 to 30 minutes for each episode. He localizes the pain to his epigastric area and states that it radiates to his right upper abdomen. He also complains nausea associate with the pain. Patient does not take any medication for the pain. Nothing can relief the pain. He notes that it became markedly worse after eating dinner last night. Denies vomiting, fever, chill, diarrhea, or fatigue. Patient reports recent evaluation by his primary doctor, Dr. Meltzer, at which time an abdominal ultrasound was performed which revealed “Gallstones”. Patient was then referred to Dr. Denoto and the above surgery was recommended.

Objectives:

Allergies: NKDA.

Current Medication:

• Amlodipine 10 mg tablet PO once per day
• Rosuvastatin 10 mg tablet once per day
• Zolpidem 10 mg tablet PO nightly as needed for sleep
• Cholecalciferol 6000 units PO once per day
• Fexofenadine 180 mg tablet PO daily as needed
• Lovaza 1g/capsules PO 2 capsules BID

Vitals:

• BP: 110/72, sitting, left arm
• HR: 72 bpm, regular
• RR: 19 breaths per minute, regular
• O2 Sat: 98%, RA
• T: 97.6 oral
• Ht: 71 in Wt: 231 lbs     BMI: 32.22 kg/m2

Physical Exam

• Gen – Obese male, well nourished, well developed resting in chair, no apparent distress
• ENT – NC/AT, no JVD noted
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Soft, non-distended. Abdominal tenderness to palpation in the right upper quadrant. Bowel sounds normoactive in all four quadrants, no masses to palpation, no hepatosplenomegaly.
• Extremities –No clubbing, cyanosis, edema, radial/DP pulses +2 bilaterally
• MS –Full range of motion throughout, strength 5/5 bilaterally throughout
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

 

Assessment

A 67-year-old male with PMHx HTN, HLD, Arthritis, Cervical Spinal Stenosis, Fatty Liver, Diverticulosis, GERD, History of Kidney Stones, BPH, Environmental and Seasonal Allergies. Patient presents to PAT today prior to scheduled Laparoscopic Cholecystectomy. History and imaging findings consistent with cholelithiasis.

Plan

• Medical Clearance by Dr. Meltzer
• Laparoscopic Cholecystectomy by Dr. Denoto on 10/5/2020.
• Advised patient to discuss with Dr. Meltzer and Dr. Denoto when and if to stop any medications prior to surgery including Lovaza. All medications reviewed
• Advised patient not to eat any solid foods after Midnight the night prior to surgery. Also advised patient to maintain clear liquid diet until 4 hours prior to scheduled surgery. List of clear liquid diet options given to patient.
• Hibiclens wash given to patient with instructions on use.
• Patient’s Guide to Managing Pain Brochure given and discussed with patient.
• Advised patient to return to PAT for COVID-19 testing on 10/2/2020. Patient verbalized understanding