[Name] is here today with her husband. She is having continuing abdominal pain. She has just seen Dr. [Name]. MRI of the abdomen is reviewed showing real no pathology except for question of the ureter, which Dr. [Name] in Urology reviewed. They relate that Dr. [Name] wanted to do an ultrasound of the gallbladder. This has yet to take place. She did have some atheromatous change and is seeing a Cardiologist, Dr.[Name], at [Place]. She has a myomatous uterus.
On exam today, she appears comfortable.
Temp 36.5. Blood pressure is 120/76. Weight is 54 kg, stable.
Chest is clear.
Cardiovascular: No murmur or gallop.
The abdomen slightly distended and doughy. Consistent with stool, but no localizing tenderness is detected.
The extremities are normal. …show more content…
Plan
I agreed that Dr. [Name] should re-exclude cholelithiasis as a cause. She should also follow up with a gynecologist to see how much trouble her fibroid is causing. Presumably not much, given the fact that she is postmenopausal. However, this needs to be checked.
Another complaint emerged at the end of the interview. She did have some blood coming from her ear. With the otoscope, there is a slight scratch with a bit of coagulated blood in the bottom of the ear canal. They were told it leave alone, and keep the area dry.
I have asked her to return. I consider that maybe she would improve with Miralax, as a cathartic because of her repeated bouts of the abdominal distention. She has been colonoscoped
On exam today, she appears comfortable.
Temp 36.5. Blood pressure is 120/76. Weight is 54 kg, stable.
Chest is clear.
Cardiovascular: No murmur or gallop.
The abdomen slightly distended and doughy. Consistent with stool, but no localizing tenderness is detected.
The extremities are normal. …show more content…
Plan
I agreed that Dr. [Name] should re-exclude cholelithiasis as a cause. She should also follow up with a gynecologist to see how much trouble her fibroid is causing. Presumably not much, given the fact that she is postmenopausal. However, this needs to be checked.
Another complaint emerged at the end of the interview. She did have some blood coming from her ear. With the otoscope, there is a slight scratch with a bit of coagulated blood in the bottom of the ear canal. They were told it leave alone, and keep the area dry.
I have asked her to return. I consider that maybe she would improve with Miralax, as a cathartic because of her repeated bouts of the abdominal distention. She has been colonoscoped