Interview on Patient with Cholecystitis]

Patient Information:
Name: Sarah Johnson
Age: 38
Gender: Female
Date of Interview: March 10, 2024

Chief Complaint:
The patient presented with the following chief complaint during the interview:

Severe abdominal pain
Medical History:

Past Medical History:
No significant medical history
Presenting Symptoms:
During the interview, the patient reported experiencing the following symptoms:

Abdominal pain
Duration: Approximately 3 days
Severity: Severe
Location: Right upper quadrant
Associated factors: Pain worsens after meals, radiates to the back and shoulder, accompanied by nausea and vomiting
Current Medications:
The patient reported taking no regular medications.

Allergies:
The patient reported no known allergies to medications or substances.
 
Social History:

Occupation: Office administrator
Tobacco Use: Non-smoker
Alcohol Consumption: Occasional social drinking
Recreational Drug Use: None reported
Family History:
The patient reported no significant family history of gallbladder problems or related conditions.

Plan:

Order diagnostic tests, including abdominal ultrasound and blood work (complete blood count, liver function tests) to confirm the diagnosis and assess the severity of inflammation



Initiate pain management with analgesics to alleviate the patient's symptoms.
NPO (nothing by mouth) status and intravenous fluids to maintain hydration.
Initiate antibiotic therapy to cover potential infectious causes.
Consult a general surgeon for consideration of cholecystectomy.
Follow-up:
The patient is scheduled for an ultrasound and blood work on March 12, 2024. A follow-up visit is scheduled for March 15, 2024, to review the test results, assess the response to treatment, and discuss potential surgical intervention if indicated.