DIAGNOSIS: TENSION HEADACHE 32 YEAR-OLD FEMALE AFRICAN AMERICAN 2 KIDS DELIVERED VIA C-SECTION MEDICAL HISTORY: GASTRITIS, ANEMIA VACCINES: HPV, COVID,? PLEASE USE THE TEMPLATE AS A

Name: AA

Date: 2/02/23

Time: 1100

 CPT code: 99396

Age: 64

Sex: F

SUBJECTIVE

CC: “I’m following up on my stomach pain and now my right shoulder hurts”

HPI: Patient is following up today on abdominal pain in the RUQ that she has been having intermittently from May 2022 to present day. An ultrasound was done in May and patient was found to have gallbladder polyps. The plan between physician and patient was to follow up for any changes and no surgical intervention at the time. Patient then returned to the office with same complaint in November 2022 and was sent to repeat ultrasound and blood work. Pt states that the abdominal pain is now continuous, dull, and rates it 5/10 on a numeric pain scale. New associated symptoms are right shoulder pain. Denies fever or chills. Pt states she hasn’t been eating much because eating makes the pain worst. Resting and ibuprofen 400 helps to relieve the pain if severe. Pt is following up since those examinations for the first time.

Patient first noticed pain to right shoulder when waking up one morning one week ago. Pain is sharp, steady, and rates it 5/10 on numeric scale. Pain is bearable and patient takes ibuprofen at times but not often. Denies any falls or trauma. Denies heavy lifting or swinging of arm.

Medications: Multivitamin orally once daily (supplement), Vitamin D3 (supplement), Procardia xl 60mg one daily (antihypertensive) and Ibuprofen 400mg OTC orally every 4 hours as needed (analgesic/antipyretic).

Past medical history: primary hypertension

Immunization: Up to date

Allergies: NKDA

Medication Intolerances: None

Chronic Illnesses/Major traumas: primary hypertension

Hospitalizations/Surgeries: c- section x 2. Repair of rotator cuff injury to right shoulder in 2010.

Family History

Mother had HTN and DM II, (deceased age 89). Father deceased at age 94, pmh unknown. 1 daughter has lupus.

Social History

A.A. is married and has 3 daughters. She is a patient care technician in a hospital. She lives in a house with her husband, 2 daughters and one grandchild. Denies smoking tobacco and illicit drug use. Denies drinking alcohol. Identifies as a Christian.

ROS

General

Denies fever. Complains of reduced energy and 5 lb. weight loss. 

Cardiovascular

Denies chest pain, palpitations, or orthopnea 

Skin

Denies any bruises, rashes, or any changes in lesions or moles.

Respiratory

Denies shortness of breath or difficulty breathing, cough, or hemoptysis.

Eyes

Denies blurred or double vision. Denies pain. Admits using corrective lenses. Denies any recent visual changes.

Gastrointestinal

Complains of RUQ pain, described as dull. Denies constipation or diarrhea. Denies vomiting, or eating disorders. Admits to occasional nausea for past 2 weeks.

Ears

Denies ringing in ears, pain, or hearing loss.

Genitourinary/Gynecological

Denies dysuria or frequency. Denies burning when urinating, Denies hematuria or change in color of urine. Admits to being menopausal

Nose/Mouth/Throat

Denies loss of smell or congestion. Denies any soreness or difficulty swallowing. Denies dental disease, hoarseness, or throat pain.

Musculoskeletal

Complains of sharp pain to right shoulder. Denies neck or back pain. Denies joint swelling or stiffness. Admits to having rotator cuff injury to right shoulder 13 years ago.

Breast

Denies lumps, bumps or changes in breasts.

Neurological

Denies syncope or paresthesia

Heme/Lymph/Endo

Denies history of anemia, easy bruising, or bleeding, petechiae, or purpura. Denies any new growths, lumps, or bumps. Denies excessive thirst or hunger. Denies cold intolerance. Denies hair loss

Psychiatric

Denies suicidality, anxiety, and depression.

OBJECTIVE

Weight 143 lbs.      BMI 24.5

Temp 98.4

BP 154/89

Height 5 ft. 4

Pulse 79

Resp 18

General Appearance

Patient is alert and oriented times four. She is well groomed and appropriately dressed. Speech is logical and well-paced. Affect is appropriate.

Skin

Skin warm to touch and with normal texture. No rashes or lesions. Good turgor and nails without clubbing.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral abnormalities. Ears: No discharge noted from ear canal. Bilateral Tympanic membranes pearly grey with positive light reflex. Nose: Nasal septum moist. No flaring of nostrils. Throat: Tonsils not edematous. Gag reflex intact. Mucus membranes moist. Oral mucosa pink and moist. Pharynx is non-erythematous and without exudate. Dentition good.

Cardiovascular

Regular rate and rhythm. No murmurs auscultated. No JVD. PMI is in the 5th inter-costal space at the mid-clavicular line. Capillary refill 2 seconds. No edema.

Respiratory

Lungs clear bilaterally. No accessory muscle use noted. Capillary refill brisk. Symmetric chest wall. Respirations regular and easy.

Gastrointestinal

Soft and no distention noted, tenderness to RUQ. No rigidity rebound tenderness, bowel sounds present in all 4 quadrants. Murphy’s sign negative

Breast

No masses, tenderness, discharge, dimpling, wrinkling or discoloration of the skin.

Genitourinary

No CVA tenderness. External genitalia reveal coarse pubic hair in normal distribution; skin color is consistent with general pigmentation.

Musculoskeletal

Normal gait. No joint deformities nor edema. Motor is 5/5 in bilateral upper and lower extremities. There is no crepitus, swelling, or deformity of the joints or bones. Tenderness with moderate palpation to right shoulder.

Neurological

Sensation to pain, touch, and proprioception normal. No pathologic reflexes. Balance stable; gait normal.

Psychiatric

Alert and oriented x 4. Dressed appropriately for weather with coat and closed shoes. Maintains eye contact. Speech is soft, thorough, clear and of normal rate. Answers questions appropriately.

Lab Tests

Urinalysis–unremarkable

Bloodwork ( TSH, CBC, BMP, Uric acid, Free T4, Liver Function tests, and Lipid panel) – unremarkable except LDL 131 mg/dl.

Abdominal Ultrasound- November 2022 ultrasound was compared to abdominal ultrasound from May 2022 and shows that the largest gallbladder polyp has increased from 0.8cm to 1.2cm.

 Diagnosis

  Differential Diagnoses

· 1- Cholecystitis

· 2- Cholesterolosis

· 3- Cholelithiasis

Final diagnosis

· Cholesterolosis ( ICD 10 K82.4)– presence of polypoid lesions on gallbladder as confirmed by ultrasound

· Pain in right shoulder (ICD 10 M25.511) – referred pain to right shoulder rated 5/10 on numeric scale

Plan/Therapeutics

· Plan: 

· Further testing: Repeat Labs for pre-surgical testing

· Medication: Meloxicam 10 mg daily for pain. According to Fraquelli, Casazza, Conte, and Colli (2016), the usual first‐line treatment for biliary colic pain are NSAIDs.

· Referral: Pt referred to Gastroenterologists for surgical removal.

· Education: Patient wished to have ultrasound repeated before confirming diagnosis and referral for possible surgery. Radiologist suggested surgical removal. Patient’s ultrasounds from 2021 and 2022 shows growth of polyps, which is causing discomfort. The patient was educated that surgery is the best option at this time. Currently, the only treatment option for gallbladder polyps is the surgical removal of the gallbladder (Caporuscio, 2021). Pt also informed that gallbladder pain can radiate to right shoulder (Caporuscio, 2021).

· Follow- up: The patient was informed to follow up after appointment with gastroenterologist and repeat bloodwork is done.