Prépique

Subjective: The patient presents for a pre-operative assessment prior to a scheduled elective laparoscopic cholecystectomy. The patient reports experiencing intermittent right upper quadrant pain, particularly after consuming fatty foods, for the past six months. The patient denies any fever, chills, or jaundice. The patient states they are anxious about the surgery and would like to discuss pain management options. Past Medical History: The patient has a history of hypertension, well-controlled with medication. They had a previous uncomplicated appendectomy at age 10. Medications - Lisinopril 10mg daily - Paracetamol as needed for pain - No known drug allergies. Objective: Blood pressure: 130/80 mmHg, Heart rate: 78 bpm, Respiratory rate: 16 breaths/min, Oxygen saturation: 98% on room air. The patient is alert and oriented. Cardiovascular examination reveals a regular rate and rhythm, no murmurs, rubs, or gallops. Respiratory examination is clear to auscultation bilaterally. Abdomen is soft, non-tender to palpation except for mild tenderness in the right upper quadrant. No guarding or rebound tenderness is present. Assessment: The patient is a 55-year-old female presenting for pre-operative assessment prior to laparoscopic cholecystectomy. The patient has symptomatic cholelithiasis. The patient's hypertension is well-controlled. ASA physical status classification: II. Plan: - Discussed the surgical procedure, risks, and benefits with the patient. - Discussed anaesthetic plan including general anaesthesia with regional analgesia. - Ordered pre-operative blood tests (FBC, U&Es, LFTs, clotting screen). - Prescribed pre-operative medications: Ondansetron 4mg IV and Ranitidine 50mg IV. - Instructed the patient to fast from midnight the night before surgery. - Scheduled the patient for surgery on 1 November 2024. - Provided the patient with information regarding post-operative pain management.