Orris

Uh, the patient came in with a chief complaint of, uh, right upper quadrant pain and vomiting. Actually, the patient, on Sunday, patient experienced this pain for the first time, and she visited another institution. Hmm. Transtupim. Aaah... "Uh, she visited another institution and was given painkiller Vascofin, uh, for which it was relieved. And after that, yesterday at 2 PM, she had, uhm, chow rice." Outside, uh, after eating, after, like, two to three hours, the pain again started, which was gradual, extreme pain and pressure, cramps, and radiating to the right breast. And the pain scale is more the, uh... According to the patient, it's more than 10. And it is associated with vomitings, like two to three times before, one time at the ER, and once after getting admitted. And the vomiting is yellow. And patient also experiences upper, upper back pain. Upper back pain. And... And due to presence of this, uh, due to persistence of these symptoms, patient consulted at the ER. Ultrasound was done, and the results showed, uh, gallbladder stones, and hence patient got admitted. Can you give this history in a proper format?

Here is the patient's history formatted as a structured clinical admission note:

History of Present Illness

Chief Complaint: Right upper quadrant (RUQ) pain and vomiting

History of Present Illness

Patient: [Name/Age/Sex - Female] Date of Admission: Monday, July 13, 2026 Admitting Diagnosis: Cholelithiasis (Gallbladder Stones)
First Episode: The patient first experienced right upper quadrant pain on Sunday (July 12, 2026). She visited an outside institution, where she was administered an analgesic (Vascofin), following which her pain was relieved and she was discharged.
Current Episode (Presenting Complaint): On Sunday, July 13, 2026 at approximately 2:00 PM, the patient consumed rice (outside food). Approximately 2-3 hours after eating, she developed a recurrence of pain with the following characteristics:
  • Location: Right upper quadrant
  • Onset: Gradual
  • Character: Extreme pain, pressure, and cramping in nature
  • Radiation: Radiating to the right breast and upper back
  • Severity: Patient rates pain as greater than 10/10 on the numeric pain scale
  • Associated symptoms:
    • Nausea and vomiting (yellow/bilious in color)
      • 2-3 episodes prior to ER visit
      • 1 episode at the ER
      • 1 episode post-admission
    • Upper back pain
Due to persistence and severity of symptoms, the patient presented to the Emergency Room (ER).

Investigations Done

  • Ultrasound (Abdomen): Revealed gallbladder stones (cholelithiasis)

Disposition

Patient was admitted for further management of symptomatic cholelithiasis.

Relevant History

  • Dietary trigger identified: Fatty/outside food (chow rice) consumed prior to onset of current episode
  • Prior treatment: Vascofin (analgesic) at outside institution - provided temporary relief
Note: The name "Vascofin" should be verified - this may be a phonetic transcription of the actual drug name (possibly Buscopan/hyoscine butylbromide or a local brand analgesic/antispasmodic). Please confirm the exact medication from the previous institution's records.

Give it according to hpi and proper format in a paragraph

History of Present Illness

The patient is a female who presents to the emergency room with a chief complaint of right upper quadrant pain and vomiting. She reports that her symptoms first began on Sunday, July 12, 2026, at which time she sought care at an outside institution and was administered Vascofin (an analgesic/antispasmodic), with subsequent relief of symptoms. Later that same day at approximately 2:00 PM, the patient consumed rice from an outside food establishment. Approximately two to three hours following this meal, she developed a gradual onset of severe right upper quadrant pain, which she describes as extreme pressure and cramping in character, radiating to the right breast and upper back, with a self-reported pain severity of greater than 10 out of 10. The pain was associated with bilious (yellow) vomiting, occurring two to three times prior to her ER visit, once upon arrival to the ER, and once following admission, totaling four to five episodes. Due to the persistence and severity of her symptoms, the patient presented to the emergency room for further evaluation. An abdominal ultrasound was performed in the ER, which revealed the presence of gallbladder stones (cholelithiasis), and the patient was subsequently admitted for further management.
This is a shared conversation. Sign in to Orris to start your own chat.