HPI: You will type this in the EMR section of the case (NOT the problem statement) CC: Abdominal pain Evita Alonso is a 48-year-old Hispanic American female. She has had abdominal discomfort for two months off and on that has increased over the last two days and now is constant. She explained the pain is located in the right side of her upper abdomen, under her ribs with radiation to right shoulder. She describes the character of the pain as crampy, gnawing, and achiness that increases when she eats a meal and the pain in her shoulder as an ache. She rates her pain at 2-3, elevates to 6-7. She has also been experiencing nausea and vomiting for the last two days along with fever and chills for two days, she has not been able to keep any nutrients down. Over the last 2 moths she has noted some bloating, decreased appetite, and increase in symptoms when she eats fast food. She has tried using antacids to treat this discomfort with no symptom relief. Plan: Type the information regarding each of the following sections into the i-Human Plan section of your case. You must address each of the 6 topics. For example, if you will not be consulting anyone then you must write “no consults indicated”. Each section of the plan is worth 5 points to total 30 points. Diagnosis: choledocholithiasis Symptoms Pain in the right upper or middle upper abdomen for at least 30 minutes. The pain may be constant and intense. It can be mild or severe. Fever, yellowing of skin and whites of the eyes (jaundice), loss of appetite, nausea, vomiting, and clay-colored stools. Essentials of DX: History of biliary pain, maybe accompanied by jaundice. Patients sometimes present with painless jaundice. Cholangitis should be suspected with fever, followed by hypothermia, and gram-negative shock, jaundice, and leukocytosis. Stones in the bile duct are best detected by EUS or ERCP Choledocholithiasis refers to the presence of one or more gallstones in the common bile duct. with the potential development of cholangitis and ascending infections. Acute common bile duct obstruction produces an acute increase in the lever of liver enzymes ALP, AST and ALT followed by increased serum bilirubin level. Evita Alonso had an elevation in ALP,AST, and ALT indicating acute obstruction along with assessment findings that corelate with choledocholithiasis diagnosis. Mild scleral icterus was noted during visual inspection if the eyes, this is also known as jaundice indicating accumulation if bile pigment (bilirubin) in the body. Diagnostic test of choice is a transabdominal ultrasound, can be performed to look for dilation of the common bile duct, along with the presence of shadowing if the gallstone can be seen.