Patient Mary Smith
record number SMITHM002 Date: 09/15/18
Chief Complaint: Mary is a 46-year-old
female who was last seen in this office 2 years ago. She is complaining of abdominal pain. This pain is different from abdominal pain that she has suffered one year ago. Her pain is sharp and stabbing, though still located in the mid- epigastrium. The pain occurs about 45 minutes after eating and lasts less than one hour. The pain occasionally radiates over right shoulder. She notes that the pain is worse after her favorite meal, pizza.
Physical Examination: she is a thin white female, appearing her stated age, weight hundred and 25 pounds, blood pressure 110/60 7 mmHg supine and 105 over 60 mmHg standing. Heart rate: 68 per minute supine and 72 per minute standing. Her conjunctiva are without pallor; mucous membranes are moist. There are no oral lesions. Is without bruit or thyromegaly. Lungs are clear to auscultation and percussion, heart is regular without murmurs, rubs, or gallops.
Abdomen is soft and no distended with normoactive bowel sounds. There is epigastric tenderness to palpation without rebound or guarding. Murphy's sign is positive. Stool is dark brown and test guaiac negative for occult blood. Deep tendon reflexes are 2 and equal. Skin is without lesions
Tests: sonogram performed in office reveals presence of gallstones. Diagnosis: cholelithiasis
Plan: discuss the recommendation for laparoscopic cholecystectomy. All benefits and risks are reviewed. Patient decides to go ahead with procedure. Surgery is scheduled for 2 weeks.
Does the documentation in the chart support the medical necessity of the tests/procedures performed? Yes No
If No, explain why: