Soap Note #6


58 year old female presented to ED 4 days ago with complaints of gnawing epigastric pain which is worse after eating fatty foods. On ultrasound, gallstones and CBD stones were seen and surgery was consulted. In the ED her LFTs were elevated ( AST: 299, ALT: 282, Alk phos:208). Over her stay in the hospital, pain has been improving on pain regimen and LFTs have been trending down.


58 year old female hospital day 4 with complaints of gnawing epigastric pain. There were no acute events overnight. Pt was seen and examined at bedside. Throughout the conversation pt remains frustrated that she has been here for so long and is still waiting for the ERCP that she is scheduled to have. Pt says that the pain is slightly improved because of the medication she is being given. She is restricted to a clear liquid diet in preparation for the ERCP and is tolerating that well. Pt admits to passing gas, but denies having any bowel movements. Pt is urinating without dysuria or hematuria. Denies nausea, vomiting, chills and back pain.


Vital signs

  • BP: 165/82 (range- 132/79 to 164/87)
  • HR: 64 bpm regular rate, rhythm and amplitude (range- 62 to 84)
  • RR: 15/min regular rate and rhythm, unlabored (range- 15 to 18)
  • Temp: 36.6 C, orally

Physical exam

  • General: Well developed, well nourished female in no apparent discomfort. Appears stated age of 58. Alert and oriented x3.
  • Lungs: Unlabored breathing, clear to auscultation bilaterally. No adventitious sounds. 
  • Heart: Regular rate and rhythm. 
  • Abdomen: Abdomen flat and symmetric with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Moderate tenderness to palpation of the RUQ and epigastric regions. No guarding or rebound noted.
  • Extremities: No erythema, warmth or crepitus noted. No pitting edema noted. Non-tender to palpation. Full range of motion of all upper and lower extremities bilaterally. 
  • Neuro: Sensation is intact bilaterally to pain and light touch. Good muscle tone. 


  • CBC
  • BMP
  • Hepatic function


58 year old female hospital day 4 for gnawing epigastric pain dx with choledocholithiasis. Pain is improving with the pain regimen. Vital signs remain within normal limits. BUN and albumin are marginally low, likely due to her NPO status. Glucose is slightly elevated, LFTs are trending down and other labs remain within normal limits.  On physical exam there is moderate tenderness of the RUQ and epigastric regions. 


  • Choledocholithiasis
    • Pain control (ondansetron 4 mg IV, Tylenol 975 mg PO Q6H PRN)
    • NPO for ERCP
    • AM labs (CBC, BMP, liver function)
    • Dextrose 5% and sodium chloride 0.45% drip  
  • Hyperglycemia
    • Insulin Lispro 1 U Q6H x3 days