**CHIEF COMPLAINT:**
Nausea.

**PRESENT ILLNESS:**
The patient is a 28-year-old who is status post gastric bypass surgery nearly one year ago. He has lost about 200 pounds and was otherwise doing well until yesterday evening around 7:00-8:00 PM when he developed nausea and right upper quadrant pain, which apparently wrapped around toward his right side and back. He feels like he was on the verge of vomiting but has not done so. He has overall malaise and a low-grade temperature of 100.3°F. He denies any prior similar or lesser symptoms. His last normal bowel movement was yesterday. He denies any outright chills or blood per rectum.

**PAST MEDICAL HISTORY:**
Significant for hypertension and morbid obesity, now resolved.

**PAST SURGICAL HISTORY:**
Gastric bypass surgery in December 2007.

**MEDICATIONS:**
Multivitamins and calcium.

**ALLERGIES:**
None known.

**FAMILY HISTORY:**
Positive for diabetes mellitus in his father, who is now deceased.

**SOCIAL HISTORY:**
He denies tobacco or alcohol use. He has what sounds like a data entry computer job.

**REVIEW OF SYSTEMS:**
Otherwise negative.

**PHYSICAL EXAMINATION:**
- Temperature: 100.3°F
- Blood pressure: 129/59 mmHg
- Respirations: 16 breaths per minute
- Heart rate: 84 beats per minute

The patient is drowsy but easily arousable and appropriate with conversation. He is oriented to person, place, and situation. He is normocephalic and atraumatic. His sclerae are anicteric. His mucous membranes are somewhat tacky. His neck is supple and symmetric. His respirations are unlabored and clear. He has a regular heart rate and rhythm. His abdomen is soft with diffuse right upper quadrant tenderness, worse focally, but no rebound or guarding. He otherwise has no organomegaly, masses, or abdominal hernias evident. His extremities are symmetrical with no edema. His posterior tibial pulses are palpable and symmetric. He is grossly non-focal neurologically.

**STUDIES:**
- White blood cell count: 8.4 (with 79 segs)
- Hematocrit: 41%
- Electrolytes: Normal
- Bilirubin: 2.8 mg/dL
- AST: 349 U/L
- ALT: 186 U/L
- Alkaline phosphatase: 138 U/L
- Lipase: Normal at 239 U/L

**ASSESSMENT:**
Choledocholithiasis, possible cholecystitis.

**PLAN:**
The patient will be admitted and placed on IV antibiotics. We will get an ultrasound this morning. He will need his gallbladder removed, probably with an intraoperative cholangiogram. Hopefully, the stone will pass this way. Due to his anatomy, an ERCP would prove quite challenging.