CHOLECYSTOPATHY

1. Chief complaint
•Cholecystopathy
2. HPI
a. Concern:
b. Onset-
•Sudden
•Gradual

c. Duration: ____
•Recent
•A few days
•Many days
•A few weeks
•Many weeks
•A few months
•Many months
•A few years
•Many years
•Recurrent
•N/A.
d. Severity:
•Mild
•Moderate
•Severe
•Absent
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit.
•Details

e. Location: Right upper quadrant

f. Radiation:
•The flanks
•Intrascapular regions
•Right shoulder
g. Quality:
•Improving
 •No change
•Worsening
•Burning pain
•Constricting
•Crushing
•Dull pain
•Heavy
•Sharp pain
•Squeezing
•Stabbing
h. Frequancy
i. Status
j. Context
k. Aggravated by :
l. Relieved by
m. Associated Symptoms
n. Pertinent Negatives
o. Notes

3. ROS

4. SYMPTOMS

•Right upper quadrant pain

•Nausea

5. HISTORY

a. FAMILY HISTORY
•Diabetes
•Obesity
b. SOCIAL HISTORY
•Alcoholism
c. PAST MEDICAL HISTORY
d. SURGICAL HISTORY
e. CHRONIC CONDITIONS

6. ALLERGIES

7. PHYSICAL EXAMINATION
•Mild right upper quadrant tenderness
8. SPECIFIC DATA LIKE GRADING
9. TESTS TO BE ORDERED
a. Liver profile
b. CBC
c. Helicobacter pylori serology
d. WBC count
e. Alkaline phosphatase
f. Bilirubin
g. Alanine aminotransferase (ALT)
h. Aspartate aminotransferase (AST)
i. Amylase/lipase assays
j. Liver function tests
k. CRP (C-reactive protein)
l. Urinalysis
m. Radiography (without contrast) abdomen
n. USG abdomen
o. Cholangiography
p. Percutaneous transhepatic cholangiography (PTC)
q. CT scan
r. MRI
s. Hepatobiliary scintigraphy
t. Endoscopic retrograde cholangiopancreatography (ERCP)
u. Endoscopic ultrasound-guided transmural cholecystostomy

10. ASSESSMENT/PLAN
•Cholecystectomy

11. EDUCATION
•Avoid fat rich diet

12. MEDICATION

13. FOLLOW UP