Gastroenterology study

DISCHARGE SUMMARY

ADMITTING DIAGNOSIS

Chronic cholecystitis with cholelithiasis.

FINAL DIAGNOSIS

Chronic cholecystitis with cholelithiasis.

PROCEDURE

Cholecystectomy with operative cholangiogram.

COMPLICATIONS

None.

HISTORY

This is a 78-year-old woman who came in to see Dr. (blank) because of a recent attack of upper abdominal pain radiating into her back that was fairly severe and had some discomfort lasting for several days.  Ultrasound of the gallbladder showed gallstones.  The patient was anxious to have this problem resolved so she would not have any further attacks.

Physical examination was unremarkable, showing an elderly female who was alert and spry and somewhat overweight.  She had no really significant abdominal tenderness.

Her white count was slightly elevated without a left shift.  As noted, the ultrasound did show the presence of gallstones.

Patient was taken to surgery and cholecystectomy and operative cholangiogram performed.  Postoperatively she has done well and advanced to a high-bulk, low-fat diet, and the wound is clean and dry.  One-half of the clips will be removed, and she will be seen in the office in a couple of days to have the remainder of the clips removed.

FOOTNOTE

Line 11.  The dictator indicates that the Final Diagnosis is the same as the Admitting Diagnosis.  The Final Diagnosis should be written out in full.

Line 37.  And (and one-half) was deleted to avoid a run-on sentence.