Calculus of bile duct without mention of cholecystitis without mention of obstruction Abdominal pain epigastric Nausea alone Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]
 
Name:  ___                   Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy

 
History of Present Illness:
___ presents with abdominal pain. Pt reports pain started a few 
weeks ago, was intermittent, epigastric, worse with food. 
Associated nausea, no emesis or diarrhea. Pain has been 
increasing and today became constant, more severe. Patient 
denies any fevers/chills. Went to ___ where he 
had CT scan which showed 2.6cm stone in his distal CBD, mild 
duct dilatation, bili 2.6. Pt transferred to BIDED for ERCP.
In ED pt given morphine and then dilaudid for pain.

ROS: +as above, otherwise reviewed and negative
 
Past Medical History:
None
 
Social History:
___
Family History:
No GB disease
 
Physical Exam:
Admission:
Vitals: T:97.5 BP:110/69 P:61 R:16 O2:100%ra  
PAIN: 2
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, mildly tender RUQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands

Discharge:
No distress
98.1, 107/59, 58, 16, 100% RA
Pain: ___
Anicteric, MMM
CTAB
RR, nl rate, no murmur
soft, nontender, nondistended, pos bowel sounds
no rash
alert, oriented, ambulates without difficulty
 
Pertinent Results:
Admission Exam:
___ 06:34PM   GLUCOSE-80 UREA N-11 CREAT-0.8 SODIUM-142 
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-24 ANION GAP-18
___ 06:44PM   LACTATE-0.7
___ 06:34PM   ALT(SGPT)-244* AST(SGOT)-138* ALK PHOS-99 TOT 
BILI-2.3*
___ 06:34PM   LIPASE-36
___ 06:34PM   ALBUMIN-4.3
___ 06:34PM   WBC-7.6 RBC-4.90 HGB-15.4 HCT-43.2 MCV-88 
MCH-31.4 MCHC-35.7* RDW-13.3
___ 06:34PM   NEUTS-60.7 ___ MONOS-4.8 EOS-4.4* 
BASOS-0.5
___ 06:34PM   PLT COUNT-220
___ 06:34PM   ___ PTT-29.8 ___
___ 06:34PM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 06:34PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 
LEUK-NEG

Discharge Exam:
___ 06:00AM BLOOD WBC-6.6 RBC-4.62 Hgb-14.3 Hct-40.8 MCV-88 
MCH-31.0 MCHC-35.1* RDW-12.5 Plt ___
___ 05:50AM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-139 
K-4.5 Cl-110* HCO3-21* AnGap-13
___ 05:50AM BLOOD ALT-184* AST-79* AlkPhos-88 TotBili-3.1*
___ 06:00AM BLOOD ALT-141* AST-47* AlkPhos-89 TotBili-2.6*

ERCP: The scout film was normal. During biliary cannulation, the 
pancreatic duct was partially filled with contrast and 
visualized proximally. The course and caliber of the duct was 
normal with no evidence of filling defects, masses, chronic 
pancreatitis or other abnormalities. The bile duct was deeply 
cannulated with the sphincterotome. Contrast was injected and 
there was brisk flow through the ducts. Contrast extended to the 
entire biliary tree. The CBD was 8mm in diameter. One filling 
defect consistent with a stone was identified in the distal CBD. 
Opacification of the gallbladder was incomplete. The left and 
right hepatic ducts and all intrahepatic branches were normal. 
A biliary sphincterotomy was made with a sphincterotome. There 
was no post-sphincterotomy bleeding. The biliary tree was swept 
with a balloon starting at the bifurcation. One stone was 
removed. The CBD and CHD were swept repeatedly until no further 
stones were seen. Excellent bile and contrast drainage was seen 
endoscopically and fluoroscopically. Overall, successful ERCP 
with sphincterotomy and stone extraction.
 
Brief Hospital Course:
___ with abdominal pain due to choledocholithiasis. 

# Choledocholithiasis:
He presented with abdominal pain and found to have 
choledocholithiasis and transaminitis. He had ERCP with stone 
extraction and sphincterotomy. He was given 5 days of cipro to 
prevent infection. Afterwards, his diet was advanced and he did 
well. He was pain free and without nausea at discharge. He was 
warned of bleeding and pancreatitis complications.

He did not have evidence of cholelithiasis. CCY may still be 
indicated. He was urged to discuss this with his PCP at follow 
up. In addition, we recommended trending LFTs until resolution 
(this was discussed with the patient).
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications

 
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days 
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours 
Disp #*8 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Choledocholithiasis
Transaminitis
Abdominal pain

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

 
Discharge Instructions:
You were admitted with abdominal pain. You were found to have a 
gall stone in your bile duct. You had a procedure to remove 
this. 

We set you up with a follow up appointment at ___. It is 
important to keep this to #1 get repeat labs to make sure your 
liver function tests return to normal and #2 to discuss a 
possible cholecystectomy (gall bladder removal).

Please avoid medications like aspirin or NSAIDs (ie ibuprofen) 
for the next 4 days. You were started on an antibiotic to 
prevent an infection in the area.
 
Followup Instructions:
___

{'abdominal pain': ['Choledocholithiasis'], 'epigastric': ['Choledocholithiasis'], 'nausea': ['Choledocholithiasis'], 'transaminitis': ['Choledocholithiasis']}