Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint): Briefly describe the patient’s main reason for admission, typically right upper quadrant (RUQ) pain.
History of Present Illness:
Onset and duration of symptoms
Character of pain (sharp, dull, cramping)
Location and radiation of pain (RUQ, radiating to back or shoulder)
Associated symptoms (nausea, vomiting, fever, chills)
Any aggravating or relieving factors (e.g., fatty meals)
Past medical history (comorbidities, previous surgeries)
Medications
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate)
General examination (appearance of illness, jaundice)
Abdominal examination (tenderness in RUQ, Murphy’s sign)
Laboratory Findings:
Complete blood count (CBC) – may show elevated white blood cell count (WBC)
Liver function tests (LFTs) – may show elevated bilirubin, alkaline phosphatase (ALP), AST, ALT
Lipase and amylase – may be elevated in acute cholecystitis
Imaging Studies:
Ultrasound – typically the first-line imaging study to diagnose cholecystitis, may show gallstones, gallbladder wall thickening, pericholecystic fluid
HIDA scan (hepatobiliary scintigraphy) – may be used if ultrasound inconclusive
Assessment:
Summarize the findings and confirm the diagnosis of acute cholecystitis.
Consider the severity of the condition (e.g., uncomplicated vs. complicated).
Plan:
Non-surgical Management (if applicable):
Intravenous fluids
Pain management
Antibiotics
NPO (nothing by mouth) initially, then progress to a clear liquid diet as tolerated
Surgical Management (typical for acute cholecystitis):
Schedule for laparoscopic cholecystectomy (removal of the gallbladder)
Progress Notes:
Document daily assessments including vital signs, pain control, toleration of diet, and any changes in the patient’s condition.
Note any laboratory or imaging results obtained during the hospitalization.
Update the plan as needed based on the patient’s progress.
Discharge:
Summarize the patient’s hospital course and current condition.
Discharge instructions including medication regimen (pain medication, dietary restrictions), follow-up appointments, and signs and symptoms to watch for.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. Always consult with a qualified healthcare provider for diagnosis and treatment.