Chief ComplamtNauseavomiting, and pain History of Present This newpatient has had three episodes of pain nausea and vomiting during the past two weeksThere has been some with these episodes Stool is normal color, patient demes claycolored stook Past Medical HistoryThe patient state she always has some degree of anorexiaNo fatty food intoleranceNo medications Physical Examination Vital signs are normal SkinNo jaundiceMucous membranes are moist EyesClear without icterus Lungs Clear HeartNormal rate and rhythm AbdomenSoft with upper right quadrant tenderness to deep palpations, no guarding Laboratory Data White count was 14 300Normal electrolytes Amylase and lipase are within normal limitsUltrasound of the gallbladder demonstrated a stone in the gallbladder and no wall thickening Ducts were not dilated Diagnosis Cholelithiasis Activate W PlanThe case was discussed with the surgeon, who will see her for possible cholecystectomy in Go to Settings the near future. MDM coding Health Science Science Nursing Share QuestionEmailCopy link Comments (0)
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