Calculus of gallbladder with other cholecystitis without mention of obstruction Acute pancreatitis Osteoporosis unspecified Leukocytosis unspecified
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Penicillins / Fosamax
 
Attending: ___.
 
Chief Complaint:
Abdominal pain
 
Major Surgical or Invasive Procedure:
Laparoscopic cholecystectomy

 
History of Present Illness:
___ yo presents with abdominal pain. Pt reports on day prior to 
presentation she ate a fatty meal and noted onset of abdominal 
pain approximately 3 hours later. She has had persistent pain 
since then. The pain is epigastric with radiation to the RUQ and 
back, assoicated w/ nausea and 3 episodes of NBNB emesis. Pt had 
temp of ___ yesterday. Reports similar episodes of pain when 
eating fatting food for the past month that were less severe and 
self resolved.  Denies chest pain, dyspnea, or cough.
In ED RUQ showed stone is bile duct. Lipase ___. Pt given 
cipro/flagyl, zofran and morphine. ERCP and ACS notifed.
On arrival to floor denies pain or nausea.

ROS: +per HPI, 10 points reviewed and otherwise neg

 
Past Medical History:
osteoporosis
 
Social History:
___
Family History:
no history of gallstones or pancreatic cancer
 
Physical Exam:
VS: 
PAIN:
GEN: nad, somnolent
HEENT: mmm
CHEST: ctab
CV: rrr
ABD: soft, tender epigastrium and RUQ, nabs
EXT: no e/c/c
NEURO: follows commands, answering questions appropriately
 
Pertinent Results:
___ 05:45PM   LACTATE-2.0
___ 04:16PM   ___ PTT-30.5 ___
___ 03:50PM   GLUCOSE-150* UREA N-17 CREAT-0.9 SODIUM-140 
POTASSIUM-3.3 CHLORIDE-98 TOTAL CO2-26 ANION GAP-19
___ 03:50PM   ALT(SGPT)-742* AST(SGOT)-726* ALK PHOS-145* 
TOT BILI-5.0*
___ 03:50PM   LIPASE-2223*
___ 03:50PM   ALBUMIN-4.1
___ 03:50PM   WBC-22.3* RBC-4.78 HGB-14.7 HCT-42.9 MCV-90 
MCH-30.8 MCHC-34.3 RDW-13.4
___ 03:50PM   NEUTS-93.3* LYMPHS-3.4* MONOS-3.0 EOS-0 
BASOS-0.3
___ 03:50PM   PLT COUNT-270

RUQ US IMPRESSION: 
1. Stone within the neck of the gallbladder but no evidence of 
cholecystitis. 
2. Somewhat limited scan due to bowel gas. Heterogeneous liver 
concerning for underlying liver disease but no evidence of intra 
or extrahepatic biliary dilatation. 

 
Brief Hospital Course:
After ED evaluation, patient was admitted for further 
evaluation.  Once hospitalized, the patient had an ERCP which 
shwed sludge in the common bile duct, which was cleared by the 
procedure.  Patient also had a RUQ US which showed 
cholelithiasis.  Patient was assumed to have a passed gallstone 
and was brought to the operating room for gallbladder removal 
with Dr. ___.  Operative report is as follows: The patient 
was brought to the operative theater.  General anesthesia was 
induced.  The patient was prepared and draped in the usual 
fashion.  A time- out was now performed.  We entered the abdomen 
through an infraumbilical smile incision, which was 
anesthetized, as all
ports were, with 0.5% Marcaine.  The incision was taken down 
bluntly to the linea ___.  Linea ___ was elevated between 
___ clamps and incised.  We now penetrated the peritoneum 
bluntly with a single pass of a blunt ___ clamp.  We now 
placed a 12 ___ type port and insufflated the abdomen to 
15 mmHg.  We now passed a 30 degree angled laparoscopic into the 
abdomen and explored.  The right upper quadrant
revealed the gallbladder was not particularly adherent to the 
surrounding tissues but was quite whitened, as typical of 
chronic cholecystitis.  It also had a layer of rather fragile 
edematous tissues around it, which were moderately
troublesome during the course of the case.  We began the case by 
placing a 12 mm port in the epigastrium, and subsequently two 5 
mm ports were placed in the subcostal regions in the mid 
clavicular and lateral clavicular lines.  We now retracted 
cephalad on the gallbladder on its fundus and pulled the ampulla 
to the right.  Using ___ as well as ___ 
dissection, we now suppressed the soft tissue
off of the lateral edge of the cystic duct area, eventually 
defining the cystic duct lateral margin.  We now slowly 
suppressed the soft tissue off of the cystic duct and allowed 
the cystic artery, which was lying fairly close over the cystic 
duct, to fall back to the patient's left by dividing some of its 
right-sided ramifications using cautery.  This now enabled us to 
isolate the cystic artery high up and divided between 2 clips 
proximally and 1 distally.  We now cleaned the remainder of the 
cystic duct and divided it between 2 clips proximally and 1 
distally.  We now commenced elevating the gallbladder off of the 
liver bed.  Because of some dense adhesions in this area, a 
cholecystotomy was made, and we spilled some bile but there was 
not a lot of stone debris seen.  All of this was irrigated free 
with a suction
irrigator, and the right upper quadrant cleansed several times 
before we finished the case.  We now completed dissecting the 
gallbladder off of the liver bed until it was
attached only by the free edge of the liver.  At this time, we 
examined the dissection area in great detail and were very 
satisfied with both hemostasis and the clips on the cystic duct. 
 The attachments of the gallbladder and the free edge
of liver were now lysed and the gallbladder pulled out through 
the epigastric port.  At this time, we once more irrigated the 
abdomen and removed all irrigant and debris. We now removed the 
trocars sequentially and found a pesky bleeder on the epigastric 
trocar site.  This was controlled with cautery from the right 
flank port site.  When this was dry, we now once more irrigated 
and were satisfied with hemostasis throughout.  The remainder of 
the ports were removed.  We now closed the umbilical port using 
the 2 stay sutures of 0 Vicryl plus an intervening 
figure-of-eight Vicryl suture.  This resulted in a very 
satisfactory closure. The skin wounds were anesthetized 
thoroughly with 0.5% Marcaine.  The subcutaneous tissues and 
skin were closed with ___ Monocryl.  Benzoin and Steri-Strips 
were applied.  2 x 2's and Tegaderm were applied.  Procedure was 
terminated.

She tolerated the procedure well and was extubated upon 
completion. She we subsequently taken to the PACU for recovery. 
She was transferred to the surgical floor hemodynamically 
stable. Her vital signs were routinely monitored and she 
remained afebrile and hemodynamically stable. She was initially 
given IV fluids postoperatively, which were discontinued when 
she was tolerating PO's. Her diet was advanced on the morning of 
___ to regular, which she tolerated without abdominal pain, 
nausea, or vomiting. She was voiding adequate amounts of urine 
without difficulty. She was encouraged to mobilize out of bed 
and ambulate as tolerated, which she was able to do 
independently. Her pain level was routinely assessed and well 
controlled at discharge with an oral regimen as needed. On ___, 
she was discharged home with scheduled follow up in ___ clinic 
in 2 weeks.
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Actonel *NF* (risedronate) 35 mg Oral ___ 

 
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain 
2. OxycoDONE (Immediate Release)  ___ mg PO Q4H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours 
Disp #*30 Tablet Refills:*0
3. Senna 1 TAB PO BID Constipation 
4. Actonel *NF* (risedronate) 35 mg ORAL ___ 
5. Docusate Sodium 100 mg PO BID 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
gallstone pancreatitis

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted to the hospital with acute cholecystitis. You 
were taken to the operating room and had your gallbladder 
removed laparoscopically. You tolerated the procedure well and 
are now being discharged home to continue your recovery with the 
following instructions.
 
Please follow up in the Acute Care Surgery clinic at the 
appointment listed below.
 
ACTIVITY:
 
o Do not drive until you have stopped taking pain medicine and 
feel you could respond in an emergency.
o You may climb stairs. 
o  You may go outside, but avoid traveling long distances until 
you see your surgeon at your next visit.
o  Don't lift more than ___ lbs for 4 weeks. (This is about 
the weight of a briefcase or a bag of groceries.) This applies 
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a 
time while your incision is healing. Ask your doctor when you 
can resume tub baths or swimming.
 
HOW YOU MAY FEEL: 
o  You may feel weak or "washed out" for a couple of weeks. You 
might want to nap often. Simple tasks may exhaust you.
o  You may have a sore throat because of a tube that was in your 
throat during surgery.
o  You might have trouble concentrating or difficulty sleeping. 
You might feel somewhat depressed.
o  You could have a poor appetite for a while. Food may seem 
unappealing.
o  All of these feelings and reactions are normal and should go 
away in a short time.  If they do not, tell your surgeon.
 
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your 
incisions. Under these dressing you have small plastic bandages 
called steri-strips. Do not remove steri-strips for 2 weeks. 
(These are the thin paper strips that might be on your 
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This 
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told 
otherwise.
o You may see a small amount of clear or light red fluid 
staining your dressing or clothes. If the staining is severe, 
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may 
resume tub baths or swimming.
 
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain 
medications. If needed, you may take a stool softener (such as 
Colace, one capsule) or gentle laxative (such as milk of 
magnesia, 1 tbs) twice a day. You can get both of these 
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain 
moving the bowels, call your surgeon. 
 
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal 
surgery. This pain is often described as "soreness". 
o Your pain should get better day by day. If you find the pain 
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by 
mouth. It is important to take this medicine as directed. o Do 
not take it more frequently than prescribed. Do not take more 
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your 
pain gets too severe.
o Talk with your surgeon about how long you will need to take 
prescription pain medicine. Please don't take any other pain 
medicine, including non-prescription pain medicine, unless your 
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of 
pain medicine.
o Remember to use your "cough pillow" for splinting when you 
cough or when you are doing your deep breathing exercises.

If you experience any of the following, please contact your 
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
 
MEDICATIONS:
Take all the medicines you were on before the operation just as 
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to 
take, please call your surgeon.
 
Followup Instructions:
___

{'Abdominal pain': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Epigastric tenderness': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Nausea': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Vomiting': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Radiation of pain to back': ['Calculus of gallbladder with other cholecystitis', 'Acute pancreatitis'], 'Elevated lipase': ['Acute pancreatitis'], 'Stone in bile duct': ['Calculus of gallbladder with other cholecystitis'], 'Sludge in common bile duct': ['Calculus of gallbladder with other cholecystitis'], 'Choledocholithiasis': ['Calculus of gallbladder with other cholecystitis'], 'Chronic cholecystitis': ['Calculus of gallbladder with other cholecystitis']}