Inpatient Case 1

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 ED report

History of Present Illness

The patient presents with abdominal pain.  The onset was 2  days ago and abrupt.  The course/duration of symptoms is constant.  The character of symptoms is achy and sharp.  The degree at onset was minimal, 2 /10.  The Location of pain at onset was right, upper and abdominal.  The degree at present is severe, 8 /10.  The Location of pain at present is right, upper and abdominal.  Radiating pain: none. The exacerbating factor is changing position.  The relieving factor is none.  Therapy today: none.  Risk factors consist of none.  Associated symptoms: nausea, vomiting, back pain, headache, denies fever and denies chills.  

 

Review of Systems

Constitutional symptoms:  No fever, no chills. 

Skin symptoms:  No jaundice, 

Respiratory symptoms:  No shortness of breath, no cough. 

Cardiovascular symptoms:  No chest pain, no palpitations, no tachycardia, no syncope. 

Gastrointestinal symptoms:  Abdominal pain, nausea, vomiting, constipation, no diarrhea, no rectal bleeding, no rectal pain. 

Musculoskeletal symptoms:  Back pain.

Neurologic symptoms:  No headache, no dizziness. 

Hematologic/Lymphatic symptoms:  Bleeding tendency negative, bruising tendency negative. 

Allergy/immunologic symptoms:  No impaired immunity, 

          Additional review of systems information: All other systems reviewed and otherwise negative.

 

Health Status

Allergies: No known allergies.

Medications: None.

Menstrual history: Last menstrual period: 2 week(s) ago.  

Past Medical/ Family/ Social History

Surgical history: 

Cesarean section ..

Family history: 

Mother

High blood pressure

Diabetes mellitus type II

.

Social history: 

Social & Psychosocial History

Social History

                Alcohol - Denies Alcohol Use Never

                Substance Abuse - Denies Substance Abuse Never

                Tobacco - Denies Tobacco Use Never (less than 100 in lifetime)

Electronic Cigarette/Vaping Denies Electronic Cigarette Use

                Electronic Cigarette Use: Never.

 

Psychosocial History

                No active psychosocial history has been recorded.

Problem list: 

Active Problems (1)

Hypothyroidism  

Physical Examination  

         Vital Signs

            Per nurse's notes.

General:  Alert, no acute distress. 

Skin:  Warm, dry, intact. 

Head:  Normocephalic, atraumatic. 

Ears, nose, mouth and throat:  Mouth: Dry mucous membranes.

Cardiovascular:  Regular rate and rhythm, No murmur, Normal peripheral perfusion. 

Respiratory:  Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal. 

Chest wall:  No tenderness.

Gastrointestinal:  Soft, Non distended, Normal bowel sounds, No organomegaly, Tenderness: Severe, right upper quadrant, left upper quadrant. 

Lymphatics:  No lymphadenopathy.

Psychiatric:  Cooperative, appropriate mood & affect. 

 

Medical Decision Making

Differential Diagnosis:  Abdominal pain, bowel obstruction, bowel perforation, renal stone, ureteral stone, biliary colic, cholecystitis, hepatitis, pancreatitis, irritable bowel syndrome, urinary tract infection, pyelonephritis, gastroesophageal reflux disease, gastroenteritis, peptic ulcer disease, gastritis, ischemic bowel, diverticulitis, acute myocardial infarction, constipation, incarcerated hernia. 

Documents reviewed:  Emergency department nurses' notes, emergency department records, prior records. 

Impression and Plan

Diagnosis

Choledocholithiasis

Gastritis

Elevated liver enzymes

 

H&P

Chief Complaint - ruq pain  

History of Present Illness

This 44 yr old female has a 2 d hx of severe ruq pain with nausea and vomiting She does not have prior similar history   Denies dark urine, jaundice, acholic stools  No melena, hematochezia noted  NO fever and chills  

Review of Systems

Constitutional:  Negative. 

Eye:  Negative. 

Ear/Nose/Mouth/Throat:  Negative. 

Respiratory:  Negative. 

Cardiovascular:  Negative. 

Gastrointestinal:  Negative except as documented in history of present illness. 

Genitourinary:  Negative. 

Hematology/Lymphatics:  Negative. 

Endocrine:  Negative. 

Immunologic:  Negative. 

Musculoskeletal:  Negative. 

Integumentary:  Negative. 

Neurologic:  Negative. 

Psychiatric:  Negative. 

All other systems are negative

 

Health Status

Allergies: 

Allergic Reactions (Selected)

No Known Allergies

Current medications:  (Selected)

Inpatient Medications

Ordered

Dilaudid (hydromorphone): 0.5 mg = 0.5 mL, IV Push, q2hr, PRN: Pain

Lactated Ringers 1,000 mL: 150 mL/hr, IV

Normal Saline Flush: 10 mL, IV Push, As Directed, PRN: line maintenance

Normal Saline Flush: 10 mL, IV Push, BID

Normal Saline Flush: 10 mL, IV Push, UD, PRN: line maintenance

Protonix Injection : 40 mg = 1 vial(s), IV Push, BID

Zofran: 4 mg = 2 mL, IV Push, q4hr, PRN: Nausea/Vomiting

Zosyn: 3.375 gm = 1 EA, 25 mL/hr, IV Piggyback, q8hr

Documented Medications

Documented

Non Formulary: "Nutra d hea", 0 Refill(s)

Synthroid: 150 mcg, Oral, Daily, 0 Refill(s)

progesterone: 0 Refill(s)

Problem list: 

All Problems

Hypothyroidism / 68268011 / Confirmed

Canceled: No Chronic Problems / NKP

 

Histories

Past Medical History: 

No active or resolved past medical history items have been selected or recorded.

Family History: 

Mother

High blood pressure

Diabetes mellitus type II

Procedure history: 

Cesarean section.

Teeth operation .

Social History    

Social & Psychosocial History

Social History

                Alcohol -Denies Alcohol Use Never

                Substance Abuse - Denies Substance Abuse Never

                Tobacco - Denies Tobacco Use Never (less than 100 in lifetime) Tobacco Use:.

                Electronic Cigarette/Vaping- Denies Electronic Cigarette Use

                Electronic Cigarette Use: Never.

 

Psychosocial History

                No active psychosocial history has been recorded.  

 

Physical Examination

Temperature     36.6       (19:40)

Systolic Blood Pressure 135        (19:40)

Diastolic Blood Pressure 80           (19:40)

Pulse     72           (19:40)

SpO2     100        (19:40)

Respiratory Rate               16           (19:40)

 

Impression and Plan

Acute cholecystitis, cholelithiasis, Mirizzi type syndrome with elevated lfts due to cbd compression

P: iv abs, pain and nausea meds, iv fluids and plan lap chole for tomorrow The nature of the procedure and poss risks of infection, bleeding, cbd injury, poss open surgery are discussed with pt and her husband and they understand and agree to proceed.

 

PROGRESS NOTES : 

Elevated lfts, trending up on 2 draws today: has prompted repeat MRI and a distal cbd stone is cause  Dr AAA to see for possible ercp.  Discussed at length with pt and his wife.

 

OPERATIVE REPORT:

PREOPERATIVE DIAGNOSIS:

Acute cholecystitis with cholelithiasis. 

POSTOPERATIVE DIAGNOSIS:

Acute cholecystitis with cholelithiasis. 

PROCEDURE PERFORMED:

Laparoscopic cholecystectomy. 

BRIEF NOTE:

This 47-year-old female was admitted through the emergency room for acute right upper quadrant pain.  Sonography reveals cholelithiasis and stone impacted in neck of gallbladder.  MRI was done due to marked elevation of liver enzymes, revealing no evidence of common bile duct stone and normal common bile duct.  She has been counseled with her husband in regard to the nature of laparoscopic cholecystectomy.  They are aware of the nature of the procedure, possible risks and complications including infection, bleeding, common duct injury and need for open surgery.  They understand and agree to proceed.

 

DESCRIPTION OF OPERATION AND FINDINGS:

After satisfactory administration of general endotracheal anesthesia and placement of the patient in the supine position, the abdominal wall was sterilely prepped and draped.  A 5 mm incision was made 5 cm above the umbilicus in the midline and the 5 mm lens through the Optiview port was used to penetrate the abdominal wall and pneumoperitoneum was established.  The patient was put in reverse Trendelenburg position, rolled to the left and upper 10 and two lateral 5 ports were placed under direct vision and local anesthetic.  Acute cholecystitis was noted with edema of the gallbladder wall, distention of the gallbladder and adherence of omentum to the gallbladder.  The omentum was taken down with the hook electrocautery device, and the gallbladder was retracted upward and laterally and dissection at the neck of the gallbladder revealed an anterior cystic artery which was encircled, clipped and divided as this was on the neck of the gallbladder.  A large neck of the gallbladder was noted with stone distally.  This was dissected laterally and down towards the cystic duct and was noted to be quite close to an insertion to the common duct.  It was felt that it would be best to leave this portion of cystic duct present with probable impacted stone within it rather than dissect near or onto the common bile duct.  This was done, and a window was created seeing the liver plate behind achieving one-half of the critical view of safety and being far lateral to what was seen as the common bile duct.  The endoscopic 35 mm stapler was inserted and used to divide the gallbladder neck completely and then the gallbladder was removed from liver bed with electrocautery.  There was a marked edema and inflammation of the posterior wall of the gallbladder necessitating blunt and sharp dissection, irrigation and suction to remove the gallbladder, which was ruptured, releasing bile into the right upper quadrant, which was suctioned free and irrigated until clear.  Hemostasis was achieved in the liver bed with electrocautery and the gallbladder was placed in an endobag and brought out the upper 10 port site.  Again, hemostasis was adequate and the cystic duct remnant was again evaluated, was completely sealed with the stapler and away from the common bile duct.  Therefore, the 10 port site fascia was closed with a fascial closure device after removal of the gallbladder in its endobag.  The abdomen was decompressed and all ports were closed with 4-0 Monocryl closure.  Dressings were applied.  The patient tolerated the procedure well.  Estimated blood loss 20 mL.  Sponge and needle counts were correct.  Anesthesia by the Kansas Medical Center Group.

 

DISCHARGE SUMMARY:

Final Diagnosis: Acute cholecystitis, cholelithiasis, choledocholithiasis

 Active Problems (1)

Hypothyroidism

Procedure: 13/2021  Lapaaroscopic cholecystectomy

Brief Clinical Presentation:  This 47 yr old female was admitted through the ABCD ER for ruq pain and nausea and vomiting  Imaging has revealed cholecystitis with cholelithiasis with stone impacted at the neck of the gallbladder  Pt has previously been healthy with no co morbidities.

Hospital Course and Treatment:  Pt was admitted and given iv fluids, pain and nausea meds and an MRI was done, revealing no cbd stones and normal cbd  The lap chole was done and the lft were noted to be increased post op with elevation of alk phos and bile  The mri was repeated and a small stone at the ampulla was suspected  Dr. AAA was consulted and ercp was recc if the lfts increased or pt had recurrent symptomatology The pt remained assymptomatic with ability to toler diet and the lfts improved . She was dismissed with plan for repeat lab and office visit in 3-4 d to determine if ercp will become necessary.

Disposition and Follow-up:  Home  See mon or tues  lab on 3/4 and call for report   Lofat diet  no lift over 20

 Active Medications

   acetaminophen-oxycodone: 1 tab(s), Oral, q6hr, 20 tab(s), 0 Refill(s), Refills: 0

   acetaminophen-oxycodone: Oral, q6hr, 20 tab(s), 0 Refill(s), Refills: 0

   acetaminophen-oxycodone: 1 tab(s), Oral, q4hr, PRN: for pain, 20 tab(s), 0 Refill(s), Refills: 0

   amoxicillin-clavulanate: 1 tab(s), Oral, q12hr, for 10 day(s), 20 tab(s), 0 Refill(s), Refills: 0

   levothyroxine: 150 mcg, Oral, Daily, 0 Refill(s), Refills: 0

   Non Formulary: "Nutra d hea", 0 Refill(s), Refills: 0

   progesterone: 0 Refill(s), Refills: 0