Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for choledocholithiasis, evaluation of new or worsening symptoms, or post-procedural management.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the reason for the visit. This may include:
For established diagnosis:
New or worsening symptoms suggestive of choledocholithiasis, such as:
Abdominal pain (right upper quadrant)
Jaundice (yellowing of the skin and eyes)
Pruritus (itching)
Nausea and vomiting
Dark urine
Light-colored stools
Fever and chills (if associated with cholangitis)
Response to previous treatment (e.g., ERCP, surgery)
For suspected diagnosis: Concerns about symptoms suggestive of choledocholithiasis.
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of choledocholithiasis diagnosis (if applicable)
Presence of gallstones (known or suspected)
Previous biliary procedures (e.g., cholecystectomy)
Comorbid conditions that might influence treatment options
Social History:
Briefly inquire about risk factors for choledocholithiasis (if not previously documented):
Obesity
Rapid weight loss
Female gender
Pregnancy
Family history of gallstones
Certain medications (e.g., estrogen)
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam to assess for:
Jaundice
Abdominal tenderness (right upper quadrant)
Murphy’s sign (palpable right upper quadrant mass with inspiration)
Hepatomegaly (enlarged liver)
Splenomegaly (enlarged spleen)
Laboratory Tests (review recent results):
Liver function tests (LFTs) – may show abnormalities like elevated bilirubin, alkaline phosphatase
Complete blood count (CBC) – elevated white blood cells may suggest infection
Amylase and lipase – may be elevated if there is pancreatic involvement
Imaging Studies (review recent results):
Briefly summarize findings from recent imaging studies, such as:
Abdominal ultrasound (may show gallstones and dilated bile ducts)
HIDA scan (hepatobiliary scintigraphy) – assesses bile flow
CT scan with contrast – may visualize gallstones and bile duct anatomy
Magnetic resonance cholangiopancreatography (MRCP) – detailed imaging of bile ducts and pancreas
Assessment (A):
Presence of Choledocholithiasis:
Based on clinical presentation, imaging studies, and laboratory findings, confirm or rule out the presence of choledocholithiasis.
Severity of Choledocholithiasis:
Assess the severity of choledocholithiasis based on symptoms, laboratory findings (e.g., degree of liver function test abnormalities), and presence of complications (e.g., cholangitis).
Treatment Response (if applicable):
Evaluate the response to previous treatment (e.g., ERCP with stone removal) based on clinical presentation and imaging studies.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the assessment and in collaboration with the patient, considering their preferences and overall health status. Options may include:
Endoscopic retrograde cholangiopancreatography (ERCP) with stone removal: This is often the first-line treatment for choledocholithiasis.
Laparoscopic common bile duct exploration: A minimally invasive surgical procedure to remove stones from the bile duct.
Open surgery: In some cases, open surgery may be necessary.
Medical management: Antibiotics for cholangitis and medications to dissolve cholesterol gallstones (not always successful).
Supportive Care:
Address symptoms like pain and pruritus with medications.
Follow-up:
Schedule follow-up visits to monitor recovery, assess for complications, and manage ongoing conditions like cholecystitis. Define the frequency of follow-up based on the treatment performed and clinical presentation.
Patient Education:
Educate the patient about choledocholithiasis