The prescription for Tylenol with codeine has been sent to Pharmacy by Dr. Nguyen office. The prescribed medication already has Tylenol, so do not add regular Tylenol. Patient may add ibuprofen as needed for pain. No driving while taking the prescribe pain medication. In 2-3 days, wean off the prescribed medication and take the regular Tylenol and ibuprofen instead.
The patient may take shower tomorrow. Do not soak the wounds in bathtub, swimming pool or beaches for 7 days. No strenuous activities (those the patient must hold breathing to perform) for four weeks.
Call Dr. Nguyen's office at 832-534-3802 to make an appoint for a follow up visit in 1-2 weeks. If there is any question or problem at home, call the office and ask to be connected to Dr. Nguyen.
GENERAL SURGERY PROGRESS NOTE
Date of Service: 12/30/2025 ***
Subjective
Interval History:
Past Medical History:
Diagnosis
Date
•
Dental crown present
•
Diverticulitis
•
GERD (gastroesophageal reflux disease)
Past Surgical History:
Procedure
Laterality
Date
•
CLAVICLE SURGERY
Right
•
FEMUR SURGERY
Left
•
REPAIR, HERNIA, INGUINAL, LAPAROSCOPIC, ROBOT-ASSISTED
Right
12/12/2025
No Known Allergies
[Prescriptions Prior to Admission]
[Prescriptions Prior to Admission]
No medications prior to admission.
[Social History]
[Social History]
Tobacco Use
•
Smoking status:
Former
Current packs/day:
0.00
Average packs/day:
1 pack/day for 10.0 years (10.0 ttl pk-yrs)
Types:
Cigarettes
Quit date:
1/1/2000
Years since quitting:
26.0
•
Smokeless tobacco:
Never
Substance and Sexual Activity
•
Alcohol use:
Yes
Comment: occasional
•
Drug use:
Not Currently
•
Sexual activity:
Yes
Partners:
Female
No family history on file.
Objective
Physical Exam:
Vital signs: Reviewed.
Labs, Imaging, and Diagnostic Studies:
Reports of lab results and imaging studies were reviewed.
Images of the CT scan *** were personally reviewed.
Labs
** No results found for the last 24 hours. **
Imaging
** No results found for the last 24 hours. **
Assessment/Plan
Assessment:
***
***
There are no active hospital problems to display for this patient.
Plan:
***
***
GENERAL SURGERY - PROGRESS NOTE
Date of Service: 12/30/2025 ***
Subjective
Interval History:
Objective
Physical Exam:
Vitals:
12/12/25 1440
BP:
135/74
Pulse:
84
Resp:
16
Temp:
97.8 °F
SpO2:
97%
Vital signs were reviewed
General:
Abdomen: non-distended, soft, appropriately tender
Wound: clean, in-tact, no erythema ***
Drain: serosanguinous
Labs, Imaging, and Diagnostic Studies:
Reports of lab results and imaging studies were reviewed.
Images of the imaging studies were personally reviewed. ***
Labs
** No results found for the last 24 hours. **
Imaging
** No results found for the last 24 hours. **
Assessment:
***
Plan:
***
Jon D Nguyen MD PA
14502 Spring Cypress Rd #800
Cypress, TX 77429
Patient: Chris Williams
DOB: 6/8/1965
(832) 534-3802
______________________________________________________
GENERAL SURGERY EVALUATION
Date of Service: 12/30/2025 ***
Referring Physician:
Primary Care Physician:
Chief Complaint: Abdominal pain
Reason for Consultation: Abdominal pain
Subjective
History of Present Illness:
The patient presented with abdominal pain that started ***
as a vague pain over the periumbilical area. The pain progressively got more severe and became sharp and localized in the right lower quadrant. The pain was associated with nausea and vomiting. No associated fever, chill, upper respiratory or urinary symptom. The patient cannot associate what may have caused the pain, what made it worse or better. There was no prior history of similar pain.
Past Medical History:
Diagnosis
Date
•
Dental crown present
•
Diverticulitis
•
GERD (gastroesophageal reflux disease)
Past Surgical History:
Procedure
Laterality
Date
•
CLAVICLE SURGERY
Right
•
FEMUR SURGERY
Left
•
REPAIR, HERNIA, INGUINAL, LAPAROSCOPIC, ROBOT-ASSISTED
Right
12/12/2025
Allergy:
No Known Allergies
[Prescriptions Prior to Admission]
[Prescriptions Prior to Admission]
No medications prior to admission.
[Current Medications]
[Current Medications]
No current facility-administered medications for this encounter.
Current Outpatient Medications
Medication
•
ascorbic acid (VITAMIN C ORAL)
•
melatonin 10 mg capsule
•
omeprazole (PriLOSEC) 20 MG capsule
Family History:
No family history on file.
[Social History]
[Social History]
Tobacco Use
•
Smoking status:
Former
Current packs/day:
0.00
Average packs/day:
1 pack/day for 10.0 years (10.0 ttl pk-yrs)
Types:
Cigarettes
Quit date:
1/1/2000
Years since quitting:
26.0
•
Smokeless tobacco:
Never
Substance and Sexual Activity
•
Alcohol use:
Yes
Comment: occasional
•
Drug use:
Not Currently
•
Sexual activity:
Yes
Partners:
Female
Review of Systems: Positive findings as per History of Present Illness.
Constitutional: No fever, chill, fatigue, loss of appetite, or weight loss.
Skin: No abscess, rash, tumor
HEENT: No pain, drainage, bleeding, in the head, eyes, ears, nose, or throat
Respiratory: No cough, wheezing, dyspnea
Cardiovascular: No chest pain, irregular heartbeat, orthopnea.
Gastrointestinal: Positive findings as per History of Present Illness.
Genitourinary: No dysuria, urinary urgency, or increase in urinary frequency.
Musculoskeletal: No bone, joint, or muscle pain or weakness
Neurological: No numbness, easily fall or loss of balance, fainting.
Endocrine: No sensitivity to heat or cold. No frequent urination.
Psychological: No depression or anxiety
Hematologic: No hemoptysis, hematemesis, hematochezia, melena, hematuria.
Objective
Physical Exam:
General: Well-developed, healthy appearing patient not in any acute distress.
HEENT: Normal findings with inspection. Pupils were round, regular, equal.
Neck: Normal symmetry. The trachea was midline. No mass.
Respiratory: Normal, unlabored respiratory effort.
Cardiovascular: No jugular venous distention. No ankle or pedal edema.
Gastrointestinal: Abdomen was non-distended, soft, tender in right lower quadrant.
No hepatosplenomegaly. No hernia.
Musculoskeletal: Bilateral upper and lower extremities appeared normal appearance.
Patient moved all four extremities.
Skin: Normal color, warm, dry. No rash, lesions, or ulcer
Neurologic: Symmetrical facial expression. Normal speech.
Psychiatric: Alert, oriented to person, place, and time.
Normal mood, affect and thought process.
Lab and Imaging Studies:
Reports of lab results and imaging studies were reviewed.
Lab Results & Imaging Studies:
Reports of lab results and imaging studies were reviewed.
Images of the imaging studies were personally reviewed.
Labs
** No results found for the last 24 hours. **
Imaging
** No results found for the last 24 hours. **
Assessment/Plan
Assessment:
Epigastric pain (R10.13)
Periumbilical pain (R10.33)
Right lower abdominal pain (R10.31)
Right lower abdominal tenderness (R10.813)
Right lower abdominal rebound tenderness (R10.823)
Leukocytosis (D72.829)
Abnormal findings on diagnostic imaging of digestive tract (R93.3)
Acute appendicitis with localized peritonitis (K35.3)
Acute appendicitis with generalized peritonitis (K35.2)
Unspecified acute appendicitis (K35.80)
Other acute appendicitis (K35.89) ***
Umbilical hernia without obstruction or gangrene (K42.9)
Counseling:
Relevant findings from history, examination, laboratory results, imaging studies and the assessment above were disclosed and explained to the patient. Appendectomy was recommended. The risk of surgery including, but not limited to, pain, bleeding, infection, and injury to adjacent tissue were explained. The patient acknowledged the benefits and risks of surgery and consent to proceed with laparoscopy and appendectomy.
Plan:
Laparoscopy, appendectomy (44970)
Umbilical hernia repair (49585) ***
Jon D Nguyen MD PA
14502 Spring Cypress Rd #800
Cypress, TX 77429
(832) 534-3802
Patient: Chris Williams
DOB: 6/8/1965
______________________________________________________
GENERAL SURGERY EVALUATION
Date of Service: 12/30/2025 ***
Referring Physician:
Reason for Consultation: Abdominal pain ***
Subjective
History of Present Illness:
Chris Williams is a 60 y.o. male who presented to the emergency room with intermittent, recurrent, postprandial epigastric pain radiating to the right upper abdomen for *** days. The pain was associated with nausea and vomiting. No associated fever, chill, diarrhea, constipation, genitourinary or respiratory symptom.
Past Medical History:
Diagnosis
Date
•
Dental crown present
•
Diverticulitis
•
GERD (gastroesophageal reflux disease)
Past Surgical History:
Procedure
Laterality
Date
•
CLAVICLE SURGERY
Right
•
FEMUR SURGERY
Left
•
REPAIR, HERNIA, INGUINAL, LAPAROSCOPIC, ROBOT-ASSISTED
Right
12/12/2025
No Known Allergies
[Prescriptions Prior to Admission]
[Prescriptions Prior to Admission]
No medications prior to admission.
[Social History]
[Social History]
Tobacco Use
•
Smoking status:
Former
Current packs/day:
0.00
Average packs/day:
1 pack/day for 10.0 years (10.0 ttl pk-yrs)
Types:
Cigarettes
Quit date:
1/1/2000
Years since quitting:
26.0
•
Smokeless tobacco:
Never
Substance and Sexual Activity
•
Alcohol use:
Yes
Comment: occasional
•
Drug use:
Not Currently
•
Sexual activity:
Yes
Partners:
Female
No family history on file.
Review of Systems:
Positive findings are as per the History of Present Illness.
Constitutional: No fever, chill, fatigue, or weight loss.
Head: No headache or facial pain. No mass.
Eyes: No pain, bleeding, discharge, or change invision
Ears: No pain, bleeding, discharge, or change in hearing.
Nose: No pain, bleeding, discharge, or change in smell.
Mouth: No pain, bleeding, or mass. No problem with teeth or gum.
Throat: No sorethroat, hoarseness, or change in voice.
Neck: No pain, stiffness, or mass.
Cardiovascular: No chest pain or discomfort, irregular heartbeat,
or shortness of breath with activity. No leg swelling.
Respiratory: No cough, wheezing, pain with breathing, or
waking up with shortness of breath.
Gastrointestinal: No nausea, vomiting, diarrhea, or constipation.
No abdominal or groin pain.
Genitourinary: No painful urination, frequent urination, or urgency with urination.
Musculoskeletal: No bone, joint, muscle pain or weakness.
Integumentary (skin & breast): No pain, rash, abscess, or mass.
Neurological: No numbness, easy falling, or fainting.
Psychiatric: No depression or anxiety.
Endocrine: No sensitivity to heat or cold. No frequent urination.
Hematologic, lymphatic: No problem with easy bleeding or clotting.
Allergic, immunologic: No complaint.
Objective
Physical Exam:
Vitals:
12/12/25 1440
BP:
135/74
Pulse:
84
Resp:
16
Temp:
97.8 °F
SpO2:
97%
Vital signs: Reviewed.
General: Patient appeared comfortable, not in pain or distress.
Eyes: Conjunctivae is clear, with no discharge nor scleral icterus.
Pupils are equally round and symmetric. Extra-ocular muscle movements are intact.
Ears, nose, mouth, throat: Normal appearance. No discharge. No hoarseness.
Neck: Supple & symmetrical. Trachea is midline. No mass.
Cardiovascular: No jugular venous distention. No ankle or pedal edema.
Heart: regular rate and rhythm. No murmur.
Respiratory: Normal breathing rate and chest excursion.
Lungs are clear to auscultation.
Gastrointestinal: The abdomen is non-distended, normal tympanic, soft, non-tender.
No hepatosplenomegaly. No hernia. ***
Genitourinary: not examined
Musculoskeletal: All extremities appeared normal. The patient moved all four.
Skin: Normal color, warm, dry. No rash, abscess, ulcer, or mass.
Neurological: Symmetrical facial expression. Normal speech.
Alert, oriented to person, place, and time.
Psychiatric: Calm, cooperative, communicative, pleasant.
Normal mood, affect, and thought process. ***
Labs, Imaging, and Diagnostic Studies:
Reports of lab results and imaging studies were reviewed.
Images of the CT scan were personally reviewed. ***
Labs
** No results found for the last 24 hours. **
Imaging
** No results found for the last 24 hours. **
Assessment/Plan
Assessment:
Epigastric abdominal pain (R10.13)
Right upper abdominal pain (R10.11)
Right upper abdominal tenderness (R10.811)
Vomiting (R11.11)
Cholelithiasis (K80.20) with obstruction (K80.21)
Cholelithiasis with acute cholecystitis (K80.00) and obstruction (K80.01)
Cholelithiasis with chronic cholecystitis (K80.10) and obstruction (K80.11)
Cholelithiasis with acute and chronic cholecystitis (K80.12) with obstruction (K80.13)
Cholelithiasis, choledocholithiasis with acute cholangitis (K80.32) and obstruction (K80.33)
Cholelithiasis, choledocholithiasis with chronic cholangitis (K80.34) and obstruction (K80.35)
Cholelithiasis, choledocholithiasis with acute and chronic cholangitis (K80.36) and obstruction (K80.37)
Cholelithiasis, choledocholithiasis, with acute cholecystitis (K80.42) with obstruction (K80.43)
Cholelithiasis, choledocholithiasis, with chronic cholecystitis (K80.44) with obstruction (K80.45)
Cholelithiasis, choledocholithiasis, with acute and chronic cholecystitis (K80.46) with obstruction (K80.47)
Non-functioning of gallbladder (K82.8)
Disease of gallbladder, unspecified (K82.9)
There are no active hospital problems to display for this patient.
Counseling:
Relevant findings from history, examination, laboratory results, imaging studies and the assessment above were disclosed and explained to the patient. The pathophysiology of gallbladder disease was explained. The options for (1) non-surgical management, (2) further evaluation with HIDA scan and/or MRCP *** or (3) cholecystectomy were considered and discussed with the patient. The risk of cholecystectomy including, but not limited to, pain, bleeding, infection, and injury to adjacent tissues, such as bile duct, blood vessels, and small intestine, were explained. The patient acknowledged the benefits and risks of surgery and consent to proceed with cholecystectomy.
Plan:
MRCP vs. ERCP per gastroenterology
HIDA scan
Laparoscopic cholecystectomy
Time on unit reviewing chart, obtain history and exam patient, counseling, and coordination for surgery: 55 minutes.