Date:
Patient:
MRN:
Clinician: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for gallstone disease
Evaluation of symptoms (if applicable)
Review of imaging results
Treatment plan discussion
History of Present Illness:
Briefly describe the patient’s current status:
Time since diagnosis of gallstone disease
Presence and severity of any symptoms (biliary colic – episodic right upper quadrant pain, nausea, vomiting)
Frequency and duration of symptom episodes
Change in symptoms since initial diagnosis
Past Medical History:
Underlying conditions (e.g., obesity, hyperlipidemia) that may increase risk
History of cholecystitis (gallbladder inflammation) or pancreatitis
Family History:
Family history of gallstones (increased risk factor)
Social History:
Not typically relevant for gallstones, but may include diet habits (high-fat diet may increase risk)
Physical Exam:
Vital Signs: May be normal unless there are complications (cholecystitis, pancreatitis).
Abdominal: Palpation for right upper quadrant tenderness (suggestive of cholecystitis).
Murphy sign (positive suggests cholecystitis) – may be included if performed.
Labs:
Labs are not routinely used for diagnosis of gallstones, but may be performed to assess for complications:
Liver function tests (LFTs) – elevated bilirubin, alkaline phosphatase, and liver enzymes may suggest cholecystitis or bile duct obstruction.
Lipase – elevated levels may suggest pancreatitis.
Consider mentioning other labs ordered as needed based on suspicion of other conditions.
Imaging:
Previous imaging studies: Briefly describe the findings of the imaging study (abdominal ultrasound) that identified gallstones. This should include:
Presence, number, size, and location of gallstones.
Current imaging studies: May be repeated depending on the clinical presentation:
If no symptoms, consider mentioning the option for observation with a plan for intervention if symptoms develop.
If symptoms are present, repeat ultrasound or consider referral for additional imaging (HIDA scan) to assess gallbladder function.
Assessment:
Summarize the current status based on symptoms, physical exam, and imaging:
Presence and characteristics of gallstones (based on imaging).
Correlation of symptoms with gallstones (biliary colic or complications).
Assessment of gallbladder function (if additional imaging was performed).
Plan:
Outline the management plan based on the assessment:
Observation: For asymptomatic patients with gallstones, observation with a plan for intervention if symptoms develop may be considered.
Medical management: Limited role for medications in dissolving gallstones. May be considered in specific situations.
Surgical intervention: Cholecystectomy (gallbladder removal) is the definitive treatment for symptomatic gallstones and is recommended for:
Patients with recurrent biliary colic
Patients with complications (cholecystitis, pancreatitis)
Referral to a gastroenterologist for further evaluation and surgical management if indicated.
Education:
Document any education provided to the patient regarding:
The nature of gallstones and their formation
The potential risks associated with gallstones (cholecystitis, pancreatitis)
The importance of a healthy diet to potentially reduce the risk of future gallstone formation
The rationale for observation, medical management, or surgical intervention depending on the situation
Prognosis:
Briefly discuss the prognosis. Untreated gallstones can lead to complications like cholecystitis or pancreatitis.
Cholecystectomy is a safe and effective treatment for symptomatic gallstones and offers a definitive cure.
For patients who choose observation, emphasize the importance of seeking medical attention if they experience symptoms.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have.
Consider mentioning the importance of pain management strategies for biliary colic episodes.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and prognosis.