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PATIENT NAME
Victor Peterson
PATIENT ID
973577
CONSULTATION
Mary Wells, MD, Gastroenterology Services
REQUESTING PHYSICIAN
Erik Lunderman, MD, Pulmonary/Respiratory Services
DATE OF CONSULTATION
10/16/2019
HISTORY
This patient, a 58-year-old male, being seen at the request of his
pulmonary/respiratory physician on Friday, October 16, has been admitted
to the hospital for elective thoracotomy and decortication for suspected
mesothelioma. The patient has a long history of asbestos exposure, having
difficulty with shoulder and arm pain, with the diagnosis of mesothelioma.
Two days ago, he developed right upper quadrant abdominal pain. The
patient has never experienced this type of discomfort; he has had no history
of acid peptic disease, no known cholelithiasis. He denies fever, chills,
hematuria, dysuria, or frequency.
PHYSICAL EXAMINATION
The exam being done at this time is limited to the abdomen where bowel
sounds are present and normal. There are no discrete masses felt. There is
fullness in the right upper quadrant, and the patient does exhibit some
minimal tenderness to palpation in the right upper quadrant. The patient has
been afebrile. Ultrasound of the gallbladder does show cholelithiasis with a
borderline common duct.
IMPRESSION
1. Status post resection of mesothelioma.
2. Cholelithiasis, rule out choledocholithiasis.
(Continued)
CONSULTATION
DISCUSSION
At the present time, the patient is known to have stones. I suspect his
discomfort is from either an episode of cholecystitis or choledocholithiasis. I
would suspect that liver function studies may be helpful in suggesting the
presence of choledocholithiasis. We will make arrangements for the LFTs and
possible sphincterotomy. Thank you very much for allowing us to participate
in the care of your patient. We will follow him along with you as necessary.
Mary Wells, MD
Gastroenterology Services
MW:KI
D: 10/16/2019
T: 10/17/2019