536 Case Scenario. Abdominal pain/Choledocholithiasis.

Choledolithiasis is gallbladder with stones. Gallstones are formed when the bile stored in the gallbladder becomes hardened like stone materials. The causes are high cholesterol, bile stones or high Bilirubin greater than 1.2mg/dL. See your doctor when you’re having unrelieved abdominal pain.Diagnostic tests can be performed such as laboratory tests, Xray, CT scan, MRI in Emergency room. Comply with doctor orders.


Account number Q005634372.

MR # Q00069593424.

Admitted date 09/14/2021 @06am.

Admission status: Inpatient admission.

Location MedTelemetry.

Room # 42114.

Attending doctor: Tommy Holbib.

Patient name: Loveme Wooden.

Resuscitation Status Full code.

Primary diagnosis Abdominal pain/ Choledocholithiasis.Hx of laparoscopic Cholecystectomy.

Secondary diagnosis: Hx of laparoscopic Cholecystectomy, Hypertension.

Isolation Status :Standard Precautions.

Is patient at risk for fall: No.

Suicidal risk: No.

Patient have her belongings : Yes.

Do you have advance Directive:No.

Copy of advance Directive on the chart.

Diet NPO after midnight except medications for Esophagastroduodenoscopy with possible biopy.Fine needle aspiration, fine needle biopsy aspiration. Fine needle injection aspiration. Consent signed and is in the chart.

Weight: 135lbs.

Height : 5feet 3inches.

Alert and oriented x4.

Laboratory results:


H/H 13.0,39.2.K.

Lactic acid : 1.9.


Magnesium 1.8 replaced 2gram of magnesium. Elevated Bilirubin 1.8mg/dl.

D545NS at 100ml/hour left forearm 20guage clean/ Patent/ Dry.

Maxipime 1gm Q6hours.

Vancomycin 1gm IV Q12hours.

Dilaudid 1mg IV Q6hours prn severe pain. Zofran 4mg IV Q4hours prn Nausea/ Vomiting Toradol 30mg IV Q6hour prn pain.

Celebex 200mg po prn Bid.

Levsin 0.25mg Q4hours prn dry mouth. Dyclofenac 37.5mg I V Q6hours prn pain.

Published by edochie99

A Registered Nurse with over twenty years of hospital experience, an author with Masters Degree in Nursing,also Bachelor Degree in Nursing,graduated in 1996 from USC,University of Southern California.MSN in 2009 University of Phoenix.

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