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HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female with past medical history
of depression and migraine headaches, who was in her usual state of health until approximately
the day of admission, at around 12:15 pm, when she started developing superior epigastric pain
radiating to her back that was intermittent in nature, lasting anywhere from 15 to 30 minutes at a
time, several times an hour, and the pain was very strong 7-10/10, sharp in nature; also going up
to the right upper quadrant to back. She denies any associated symptoms, including shortness of
breath, dizziness, lightheadedness, syncope, nausea, vomiting, and diaphoresis. She was
brought into the ER for a bedside ultrasound by the ER physician, Dr. Lopez, which showed
gallstone. Formal ultrasound showed a gallbladder containing a large gallstone with tenderness
suggestive of cholecystitis, and she was then admitted for further workup. She also had an
elevated lipase, suggestive of pancreatitis and gallstone pancreatitis.
FAMILY HISTORY: Mother had hypertension and depression. Father had MI.
REVIEW OF SYSTEMS: All systems reviewed and negative except as per HPI. All
other pertinent positives and negatives were reviewed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4 degrees Fahrenheit. Pulse 72. Respiratory rate 18. Blood
pressure 129/74. O2 sats 99% on room air.
GENERAL: Alert.
HEENT: PERRLA.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, mildly tender to palpation in the superior epigastric region of
right upper quadrant region. No guarding. No rebound. Normoactive bowel
sounds. No hepatosplenomegaly.
MUSCULOSKELETAL: No clubbing, cyanosis, or edema.
NEURO: No focal deficits.
Sodium 138, potassium 3.5, bicarb 23, creatinine 0.5, glucose 149. ALT and AST 50, alkaline
phosphatase 129, total bilirubin was normal at 1.1, lipase is 367.
The patient's case was discussed with the translator over the video screen, as
well as the patient's husband, and the ER physician Dr. Nicholas Lopez.