General Surgery Clinic Letter

Specialty: General Surgeon Diagnosis: 1. Cholelithiasis 2. Chronic cholecystitis Past Medical and Surgical History: 1. Hypertension 2. Type two Diabetes Mellitus 3. Appendicectomy (10 years ago) Plan: 1. Proceed with laparoscopic cholecystectomy 2. Pre-operative blood tests 3. Pre-operative anaesthetic assessment 4. Follow-up appointment in six weeks post-surgery This letter concerns Mrs. Eleanor Vance, a seventy-two-year-old female, who presents with recurrent episodes of right upper quadrant pain, consistent with cholelithiasis and chronic cholecystitis. Her past medical history includes well-controlled hypertension and Type two Diabetes Mellitus, for which she takes regular medication. She underwent an appendicectomy ten years ago without complications. Mrs. Vance lives with her husband and denies any significant family history of gastrointestinal diseases. She is currently taking AMLODIPINE five milligrams once daily and METFORMIN five hundred milligrams twice daily. She has no known drug allergies. She occasionally enjoys a glass of wine on social occasions and is a non-smoker. On physical examination, Mrs. Vance appeared comfortable at rest. Abdominal examination revealed a soft, non-distended abdomen with mild tenderness in the right upper quadrant upon deep palpation. Murphy's sign was positive. Bowel sounds were normoactive. No organomegaly or masses were palpable. Her vital signs were stable, and she was afebrile. The management plan discussed with Mrs. Vance involves proceeding with a laparoscopic cholecystectomy. This procedure was explained in detail, including potential risks and benefits. She has been advised to undergo pre-operative blood tests and an anaesthetic assessment. A follow-up appointment will be scheduled for six weeks post-operatively to review her recovery and discuss the histopathology results. She verbalised understanding and consent for the proposed management. Yours sincerely, Professor Alistair Finch Consultant General Surgeon