CHOLELITHIASIS SOAP NOTE
Cholelithiasis SOAP
note Spring Arbor
University Brett Locke
, CHOLELITHIASIS SOAP NOTE
Name: S.S. Date : 11/21/2019 Time : 0845
DOB: 6/4/1997 Sex: Female
Subjective
CC: RUQ abdominal pain and gallstones
HPI: Mrs. Snyder is a pleasant 22-year-old female who presents to the office today for
evaluation of right upper quadrant abdominal pain that has been present intermittently for
roughly one year. Her symptoms have progressively gotten worse over the past 4 weeks. She
complains of intermittent, sharp/stabbing, right upper quadrant abdominal pain that can occur
after any meal, but particularly after foods that are high in fats. The pain typically lasts about 2
hours. She reports nausea and vomiting when she is having pain. She denies diarrhea,
constipation, fever, chills or night sweats. She rates her pain at 7/10 when at its worst. She was
evaluated in the emergency department on 11/15/19 as her pain was not improving. She
underwent a right upper quadrant ultrasound while in the ED that demonstrated cholelithiasis
with multiple prominent mobile shadowing gallstones. There was no evidence of cholecystitis.
Her common bile duct measured 5-6 mm by ultrasound. Her AST was elevated at 433, ALT at
396. LDH was not performed at that time however, this was drawn in July and was elevated at
268. A lipase was obtained while at the ED which returned at 143. An amylase was not
performed.
Medications:
ProAir HFA 108 (90 base) mcg/ACT aerosol solution, 2 puffs q 6 hours prn
Albuterol Sulfate (2.5 mg/3 ml) 0.083% nebulization, 3 ml inhalation per nebulizer q 8 hours
prn
Advair Diskus 100-50 mcg/dose aerosol powder breath activated, 1 puff inhalation BID
Venlafaxine 150 mg, 1 tablet with food by mouth once daily
Allergies:
Amoxicillin – reaction: hives
PMI
Illnesses/Injuries
Childhood – Varicella
Adult – Asthma, Depression
Hospitalizations/Surgeries:
Oral extraction, wisdom teeth, 2013
Vaccinations
Influenza – 11/1/19 Pneumovax – n/a Tetanus – 1/2018 HPV – completed a 3-dose
series: 2/2015, 4/2015, 8/2015
Health Maintenance:
Last mammogram – n/a, not indicated at this time. Begin screening per protocol
Cholelithiasis SOAP
note Spring Arbor
University Brett Locke
, CHOLELITHIASIS SOAP NOTE
Name: S.S. Date : 11/21/2019 Time : 0845
DOB: 6/4/1997 Sex: Female
Subjective
CC: RUQ abdominal pain and gallstones
HPI: Mrs. Snyder is a pleasant 22-year-old female who presents to the office today for
evaluation of right upper quadrant abdominal pain that has been present intermittently for
roughly one year. Her symptoms have progressively gotten worse over the past 4 weeks. She
complains of intermittent, sharp/stabbing, right upper quadrant abdominal pain that can occur
after any meal, but particularly after foods that are high in fats. The pain typically lasts about 2
hours. She reports nausea and vomiting when she is having pain. She denies diarrhea,
constipation, fever, chills or night sweats. She rates her pain at 7/10 when at its worst. She was
evaluated in the emergency department on 11/15/19 as her pain was not improving. She
underwent a right upper quadrant ultrasound while in the ED that demonstrated cholelithiasis
with multiple prominent mobile shadowing gallstones. There was no evidence of cholecystitis.
Her common bile duct measured 5-6 mm by ultrasound. Her AST was elevated at 433, ALT at
396. LDH was not performed at that time however, this was drawn in July and was elevated at
268. A lipase was obtained while at the ED which returned at 143. An amylase was not
performed.
Medications:
ProAir HFA 108 (90 base) mcg/ACT aerosol solution, 2 puffs q 6 hours prn
Albuterol Sulfate (2.5 mg/3 ml) 0.083% nebulization, 3 ml inhalation per nebulizer q 8 hours
prn
Advair Diskus 100-50 mcg/dose aerosol powder breath activated, 1 puff inhalation BID
Venlafaxine 150 mg, 1 tablet with food by mouth once daily
Allergies:
Amoxicillin – reaction: hives
PMI
Illnesses/Injuries
Childhood – Varicella
Adult – Asthma, Depression
Hospitalizations/Surgeries:
Oral extraction, wisdom teeth, 2013
Vaccinations
Influenza – 11/1/19 Pneumovax – n/a Tetanus – 1/2018 HPV – completed a 3-dose
series: 2/2015, 4/2015, 8/2015
Health Maintenance:
Last mammogram – n/a, not indicated at this time. Begin screening per protocol
