DC is a 46-year-old female who presents with a 24-hour history of RUQ pain. She states the pain started about 1 hour after a large dinner she had with her family. She has had nausea and on instance of vomiting before presentation.
PMH:Vitals:HTNTemp: 98.8oFType II DMWt: 202 lbsGoutHt: 5’8”DVT – Caused by oral BCPsBP: 136/82HR: 82 bpm
Current Medications:Notable Labs:Lisinopril 10 mg dailyWBC: 13,000/mm3HCTZ 25 mg dailyTotal bilirubin: 0.8 mg/dLAllopurinol 100 mg dailyDirect bilirubin: 0.6 mg/dLMultivitamin dailyAlk Phos: 100 U/LAST: 45 U/LALT: 30 U/L
Allergies:
- Latex
- Codeine
- Amoxicillin
PE:
- Eyes: EOMI
- HENT: Normal
- GI:Nondistended, minimal tenderness
- Skin:Warm and dry
- Neuro: Alert and Oriented
- Psych:Appropriate mood
