Medical Text: Admission Date:  [**2142-12-23**]              Discharge Date:   [**2142-12-30**]

Date of Birth:  [**2070-6-15**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right upper quadrant pain

Major Surgical or Invasive Procedure:
[**2142-12-23**]: ERCP with sphincterotomy and stent placement
[**2142-12-28**]: cholecystectomy


History of Present Illness:
This is a 72 year-old female with a history of mild mental
retardation, who presents with RUQ that started this AM. Pt with
some back pain. Pt went to [**Hospital1 **] and was found to have a fever
of 102.9 and elevated LFTs. RUQ u/s with concern for stone in
CBD. WBC was 9.4 and 56% bands, tbili 8.7, dbili 5.3 and she was
given levo/flagyl, tylenol, and IVF and transfered to [**Hospital1 18**] with
presumed cholangitis. She is orientated to person and
"hospital". Lives at home.

In the ED, VS on arrival were 97.3 82 132/74 20 96% 2L NC. Pt
was given IVF, unasyn, zofran, and morphine. Labs showed WBC of
31, lactate 3.2, and bili of 7.7 with elevated LFTs. ERCP and
surgery were consulted. ERCP wanted pt in [**Hospital Unit Name 153**] for ERCP tonight.
Surgery requested u/s and CT abd with contrast. CXR with concern
for LLL PNA, but no resp sx. RUQ u/s prelim showed: gallstones,
no evidence of acute cholecystitis. Angiomyolipoma in left upper
pole, 1.5cm. CT prelim showed: No intrahep bil dil. Slight
enhancement of the normal caliber cbd, cbd raises the
possibility of cholangitis. Pulmonary bronchiectasis. Pt was
admitted to surgery in [**Hospital Unit Name 153**]. VS on transfer were 98 66 104/39 16
99% 2LNC.
Pt went for an ERCP that showed pus in the bile duct with a
small stone causing obstruction. There was also a stricture
1/3rd of the way in the CBD. Malignacy can not be ruled out. A
stent was placed that will need removal in 3 weeks. Pt was given
3 liters LR by the time she arrived post procedure in the [**Hospital Unit Name 153**]
including her ER IVF.


Past Medical History:
-Mild mental retardation
-Arthoscopy of knee
-Hysterectomy
-Low plts at [**Hospital1 2025**] [**2129**], dx with ITP
-Cataract surgery
-Right 3rd nerve palsy
-Esophageal web, with food obstruction removed in past


Social History:
Lives with her sister, brother-in-law, and mother. [**Name (NI) **] tobacco or
etoh use. Ambulates independently. Enjoys watching the TV and
news and Today show.

Family History:
no bleeding or plt disorders

Physical Exam:
Vitals: 98.8 87 97/36 13 94%RA
GEN: Well-appearing, no acute distress
HEENT: mild sclera ictericus, MMM, OP Clear
NECK: JVP at 5-6cm, no bruits, no cervical lymphadenopathy,
trachea midline
COR: RRR, soft SEM at Rt 2nd ICS, radial pulses +2
PULM: Lungs with coarse crackles at right bsea with decreased BS
at left base and few crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses, neg Murphys
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person and time, and "hospital".
Moving all ext, right third nerve palsy (in abduction at rest
and no elevation past midline and no adduction) and pupil is
asymetric offcenter but contract; CN otherwise grossly intact.
SKIN: Mild jaundice


Pertinent Results:
Admission labs-

[**2142-12-23**] 04:54PM BLOOD WBC-31.3* RBC-5.04 Hgb-13.2 Hct-38.0
MCV-75* MCH-26.1* MCHC-34.7 RDW-13.9 Plt Ct-162
[**2142-12-23**] 04:54PM BLOOD Neuts-57 Bands-30* Lymphs-6* Monos-2
Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-0
[**2142-12-23**] 04:54PM BLOOD PT-16.0* PTT-27.9 INR(PT)-1.4*
[**2142-12-23**] 04:54PM BLOOD Glucose-106* UreaN-18 Creat-0.8 Na-141
K-3.4 Cl-108 HCO3-20* AnGap-16
[**2142-12-23**] 04:54PM BLOOD ALT-263* AST-184* AlkPhos-172*
TotBili-7.7*
[**2142-12-23**] 04:54PM BLOOD Lipase-14
[**2142-12-24**] 12:08AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.7
[**2142-12-23**] 05:08PM BLOOD Lactate-3.2*

[**2142-12-23**] Liver US :
Gallstones, without gallbladder wall thickening or
pericholecystic fluid to suggest acute cholecystitis. No biliary
dilation.

[**2142-12-23**] CT Abd/pelvis :
1. No intrahepatic biliary ductal dilatation, no gallstones, the
gallbladder
is normal in appearance.

2. Slight mural hyperenhancement of the nondilated common
hepatic and common bile duct - can be seen with cholangitis.
2. Diverticula, no evidence of diverticulitis.

[**2142-12-23**] ERCP :
Esophageal web
Periampullary diverticulum
Successful biliary cannulation.
A single stricture that was 6 mm long was seen at the middle
third of the common bile duct.
There was an irregular appearance to the lining of bile duct,
likely secondary to cholangitis.
Sucessful sphincterotomy performed
Small 4mm stone was extracted.  Pus was seen exiting the bile
duct.
Successful plastic biliary stent placement
Otherwise normal ercp to third part of the duodenum
Possible Mirizzi's versus tumor as a cause of stricture.

[**2142-12-26**] CXR ;
1. New small-to-moderate right-sided pleural effusion with
parenchymal
opacity which could probably be explained by compressive
atelectasis, although pneumonia is an additional differential
consideration.
2. Similar left lower lung opacity which is a more chronic
finding.

[**2142-12-28**]:

INDICATION: CBD stricture of unclear etiology. Evaluate for
pancreatic mass.

COMPARISON: CT of the abdomen [**2142-12-23**] and ERCP [**12-23**], [**2142**].

TECHNIQUE: Multidetector helical scanning of the abdomen was
performed prior
to and following the administration of 200 cc of IV Optiray
contrast.
Coronal, sagittal, volume-rendered and MIP reformats were
displayed.

CTA OF THE ABDOMEN: Left lower lobe bronchiectasis and small
bilateral
pleural effusions are unchanged from prior exam. There is
pneumobilia and a
common bile duct stent in place traversing the mid CBD stricture
seen on ERCP.
There is no soft tissue surrounding the CBD to definitively
suggest a biliary
malignancy. There is mild intrahepatic biliary ductal dilation.
There is an
8-mm low-density lesion within segment V/VI of the liver
(3A:43), which is too
small to characterize but likely a cyst.

No intrahepatic lesions. The portal vein is patent. The hepatic
arterial
anatomy is conventional. The pancreas enhances homogeneously and
there is no
evidence of a pancreatic mass. The superior mesenteric artery
and vein are
patent and normal in caliber and course. There is a prominent 12
mm portal
hilar lymph node (3B:110), likely reactive. There is also a
13-mm precaval
node (3B:119).

The spleen, gallbladder, and adrenal glands are normal. The
kidneys enhance
and excrete contrast symmetrically with multiple subcentimeter
hypoattenuating
lesions which are too small to characterize but likely cysts. A
16-mm
exophytic fat-containing left renal lesion is consistent with an
angiomyolipoma (3A:66). There is a left extrarenal pelvis. No
ascites. No
mesenteric adenopathy. The small bowel loops are normal. There
are
moderately extensive colonic diverticula.

The bones are mildly osteopenic and there are degenerative
changes, however,
no concerning lytic or sclerotic lesions.

IMPRESSION: Mild biliary dilation and stent within the CBD, with
no
pancreatic or biliary mass identified.

The study and the report were reviewed by the staff radiologist.

DR. [**First Name (STitle) 18394**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18395**]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2142-12-29**] 10:56 PM

Brief Hospital Course:
This is a 72 year-old female with a who presented with acute
cholangits and was transfered for a ERCP and surgery evalaution.


# Acute Cholangitis: Pt has elevated LFTs and bili with RUQ pain
and fever of 102.9 at OSH. She was transfered for ERCP and
surgery eval. Pt had appearance of sepsis due to WBC from 9.4
with 56% bands at OSH to WBC of 31.3 and 30% bands in [**Hospital1 18**] ER
and fevers. ERCP showed stone obstruction with drainage of pus,
and stent was placed. Pt was admitted to the [**Hospital Unit Name 153**] post procedure
and remained NPO. Her LFTs started to down trend post ERCP. 2
hours post ERCP she developed some hypotension with BP dropping
from mid 90s to 70s. She was mentating and making urine. She was
given IVF bolus with LR and her BP improved to 90-100. She was
given IVF as needed to maintain UO and SBP>90. She had no
further abd pain post procedre. She continued on tx with unasyn.
[**2142-12-23**] OSH blood cx are growing GNR 2/4 bottles as of [**2142-12-24**]
at 9AM. She was transferd to the SICU per request of the surgery
team.

# CBD Stricture: On ERCP pt was found to have a stricture of
unclear cause. She then had a pancreatic protocol CTA, which
showed Mild biliary dilation and stent within the CBD, with no
pancreatic or biliary mass identified.

# Cholelithiasis:  Following ERCP and sphincterotomy with stone
extraction, pt clincally stabilized and her LFTs gradually
returned to [**Location 213**].  At this point, she was taken to the
operating room for definitive management of her cholelithiasis.
Pt was found to have acute suppurative cholecystitis and
laproscopic cholecystectomy was performed.  She recovered
uneventfully from this procedure.

# Atrial fibrillation: She developed RAF to 150 on [**2142-12-25**] and
was given IV lopressor and subsequently Diltiazem with
conversion to NSR.  No further episodes.

# Possibe PNA: no clear resp sx or hypoxia. CT Abd showed some
lower lung fields with pulm bronchiectasis, which may expalin
the ER findings on her CXR. She has a 3 liter oxygen requirment
which is likely from IVF given in setting of sepsis.

Following transfer to the Surgical floor she continued to make
good progress.  She remained free of any arrhythmias and was
gradually weaned off of oxygen with adequate saturations.  She
was up and ambulating independently and voiding without
difficulty.  Her diet was gradually advanced to regular and well
tolerated.


Medications on Admission:
Multivitamin

Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Take while using oxycodone to avoid constipation.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
cholangitis
choledocholithiasis
gram negative bacteremia
paroxsymal atrial fibrillation


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
* You were admitted to the hospital with abdominal pain due to a
stone in your bile duct.  You underwent ERCP with stent
placement.
* You had a surgery and your gallbladder was removed.
* You should continue to eat a regular diet and stay well
hydrated.
* Take the antibiotics as prescribed.
* You had an irregular heartbeat for a short time when you were
in the ICU.  It normalized with a medication called lopressor.
You will continue that until Dr. [**Last Name (STitle) 39288**] evaluates you in thge
office.
* If you develop any more abdominal pain or any other symptoms
that concern you, please call your doctor or return to the
Emergency Room.
* You will need to have the stent removed later on.  Please call
the number below to schedule an appointment.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication.  Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed.  You
may not drive or heavy machinery while taking narcotic analgesic
medications.  You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids.  Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions.  Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**12-27**] weeks.

Call the GI unit at [**Telephone/Fax (1) 1983**] to schedule an appointment for
a repeat ERCP with stent removal in 3 weeks.

Call Dr. [**Last Name (STitle) 39288**] for a follow up appointment in 2 weeks.




ICD9 Codes: 0389, 2875