PATIENT NAME: Janice McClure
HOSPITAL NO.: 11049
CONSULTANT: Bernard Kester, MD, Surgical Services
REQUESTING PHYSICIAN: Kenneth Shaker, MD, Primary Care Physician DATE: 03/12/----
REASON FOR CONSULTATION: Please evaluate acute abdominal pain for possible surgical intervention. I am asked to see this 62-year-old Caucasian female, who was admitted with abdominal pain, nausea, and vomiting. No melena or hematemesis. Pain is in the right epigastrium and right upper quadrant. She has a prior history of similar bouts but not as bad. She was evaluated in the ER and an obstruction series and abdominal sonogram were ordered by her PCP, Dr. Shaker. X-rays showed calcification in the right upper quadrant consistent with cholelithiasis. She had a low-grade fever and some chills. No apparent jaundice. She had a uterine and bladder suspension in 1992. She is multiparous. She had an appendectomy at the age of 18. No history of pancreatitis, alcohol abuse, ulcers, liver disease, or hepatitis. Physical examination reveals a woman who appears her stated age. She appears to be in considerable discomfort. Temperature 99 Fahrenheit. No apparent jaundice. Neck is normal. Abdomen shows tenderness and guarding in the epigastrium, and right upper quadrant. No other mass, hepatosplenomegaly, or hernias noted. Pelvic and rectal, unremarkable. DIAGNOSTIC DATA: White blood cell count 10.1 with 79% segs. PTT is normal. SMA shows elevated bilirubin at 1.54 with alkaline phosphatase at 442. Sonography reveals multiple gallstones with a stone in the common bile duct. These were reviewed by Dr. Singh, radiologist. Chest x-ray was unremarkable. IMPRESSION: Cholelithiasis, choledocholithiasis, and early obstructed jaundice. RECOMMENDATION: This patient is currently n.p.o. on IV fluids and antibiotics. She had initially showed interest in laparoscopic cholecystectomy; however, in view of her common duct stone. I talked...