Obstruction of bile duct Other specified abnormal findings of blood chemistry Epigastric pain Hypothyroidism unspecified Major depressive disorder single episode unspecified Hyperlipidemia unspecified Personal history of nicotine dependence Other specified soft tissue disorders Essential (primary) hypertension
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
tetracycline
 
Attending: ___.
 
Chief Complaint:
Abnormal LFTs
 
Major Surgical or Invasive Procedure:
ERCP with stent

 
History of Present Illness:
Ms. ___ is a ___ woman with history of depression, 
hypothyroidism, nephrolithiasis and several months of morning 
"fogginess" transferred from ___ after her PCP 
referred her to the ED for elevated LFTs and MRI reportedly 
showed "CBD stricture vs malignancy or stone." RUQUS in our ED 
confirmed CBD intrahepatic biliary ductal dilation and CBD up to 
1.7cm. No evidence of cholangitis. Admitted for further workup 
including MRCP. 

Ms. ___ presented to her PCP about ___ month or two ago 
complaining of feeling "foggy" in the morning, the sensation 
that she could not concentrate. Initially, her TSH was rechecked 
and her levothyroxine dose was adjusted upwards to her current 
dose. This did not seem to help so her PCP did routing liver 
function tests and discovered elevated AST/ALT and alkaline 
phosphatase. Wokrup including HBV, HCV HAV were all negative and 
per records, she had an RUQUS done on ___ which showed dilated 
hepatic bile duct and possible fatty infiltrate. She had noted 
ETOH use the weekend prior .  She was referred to her local 
hospital, ___, and reportedly an MRI was done 
which showed, "CBD stricture vs malignancy or stone," and 
referred her to ___ for potential ERCP. Upon arrival to 
us, she was feeling well, no complaints currently. 

She denies ab pain but does note that her urine has seemed more 
dark lately and she did have one bowel movement about a week ago 
that was tan colored instead of her usual brown. 

ROS: 
(+)also notes headaches occasionally, also notes feeling 
slightly "bloated" in her abdomen
(-)comprehensive ROS was otherwise negative. 
 
Past Medical History:
Hypothyroidism
Depression
Hyperlipidema (although not on statin currently)
Nephrolithiasis (long time ago, passed a kidney stone)

Past Surgical History: 
-prior eye surgery many years ago to correct a strabismus when 
she was a child

 
Social History:
___
Family History:
She notes that her mother had an episode of "jaundice" many 
years ago and has since passed away from other causes. She 
cannot recall the etiology (if any) to which this was attributed 
to. 
 
Physical Exam:
VS:  06.7  P82  138/91 R18  97% on RA
GEN: Alert, lying in bed, no acute distress, alert and talkative 
with a ___ accent
HEENT: MMM, anicteric sclera, no conjunctival pallor  
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi  
COR: RRR, normal S1/S2, no murmurs 
ABD: Soft, NT ND, normal BS  
EXTREM: Warm, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal 

 
Pertinent Results:
___ 09:36PM   LACTATE-1.1
___ 09:19PM   GLUCOSE-83 UREA N-15 CREAT-0.7 SODIUM-138 
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-20* ANION GAP-18
___ 09:19PM   estGFR-Using this
___ 09:19PM   ALT(SGPT)-674* AST(SGOT)-316* ALK PHOS-334* 
TOT BILI-1.1 DIR BILI-0.6* INDIR BIL-0.5
___ 09:19PM   LIPASE-136*
___ 09:19PM   ALBUMIN-4.5
___ 09:19PM   WBC-6.5 RBC-4.40 HGB-12.9 HCT-38.5 MCV-88 
MCH-29.3 MCHC-33.5 RDW-14.3 RDWSD-45.9
___ 09:19PM   NEUTS-52.2 ___ MONOS-6.5 EOS-2.2 
BASOS-0.5 IM ___ AbsNeut-3.38 AbsLymp-2.48 AbsMono-0.42 
AbsEos-0.14 AbsBaso-0.03
___ 09:19PM   PLT COUNT-282
___ 09:19PM   ___ PTT-32.4 ___

Impression: Normal major papilla.  
Cannulation of the biliary duct was successful and deep with a 
sphincterotome using a free-hand technique.  
A single stricture that was 5 mm long was seen at the middle 
third of the common bile duct just below the cystic duct 
takeoff.  
There was moder post-obstructive dilation with the upstream 
bile duct measuring 15mm.  
A sphincterotomy was performed in the 12 o'clock position using 
a sphincterotome over an existing guidewire. 
Spy cholangioscopy was performed.  ___ stricture was 
noted under direct visualization: it appeared as a tapered 
lumenal narrowing without neovascularization/tumor vessels or 
papillary mucosal projections noted.  
___ the main bile duct appeared normal to the 
bifurcation.  
___ cystic duct also appeared normal.  
___ forceps were taken of the stricture for 
histopathology.

Cytology samples were obtained for histology using a brush in 
the middle third of the common bile duct. 
A 7cm by ___ ___ biliary stent was placed 
successfully using a Oasis stent introducer kit. 
 

Recommendations: Return to ward under ongoing care. 
NPO overnight with aggressive IV hydration with LR at 200 cc/hr 

If no abdominal pain in the morning, advance diet to clear 
liquids and then advance as tolerated 
CT pancreas protocol 
Ciprofloxacin 500mg PO BID x 5 days. 
Follow up path and cytology reports; further management will 
depend on the results. Please call Dr ___ office at ___ in 7 days for the results. 
Repeat ERCP in 6 weeks for stent pull and re-evaluation 
Follow-up with Dr. ___ as previously scheduled. 
Follow for response and complications. If any abdominal pain, 
fever, jaundice, gastrointestinal bleeding please call ERCP 
fellow on call ___
 

 
Brief Hospital Course:
A/P:  ___ woman with history of depression, hypothyroidism, 
nephrolithiasis and several months of morning "fogginess" 
transferred from ___ after her PCP referred her to 
the ED for elevated LFTs and ultrasound showing intrahepatic 
ductal dilatation. RUQUS in our ED confirmed CBD intrahepatic 
biliary ductal dilation and CBD up to 1.7cm. No evidence of 
cholangitis. Admitted for further workup including MRCP.

#CBD stricture/bile obstruction: asymptomatic infiltrative 
pattern with elevated AST/ALT into the 100s with moderately 
elevated alk phos. Would expect a higher bilirubin with biliary 
obstruction but seems like it may have been higher recently 
given previous acholic stools and dark urine which were 
reported.  The biliary ductal dilatation is concerning for 
obstruction, either due to stone or malignancy. There is no 
evidence of cholangitis either on exam or by labs.  MRCP at OSH 
reviewed, consistent for CBD stricture near cystic duct, dilated 
pancreatic duct, no clear mass/stone.  She underwent ERCP 
confirming CBD stricture, bx sent.  stent placed.  She did well 
post procedure and her diet was advanced.  SHe was given Cipro 
500mg BID x5 days.
- Her plan will be for her to follow up with ERCP and have 
repeat ERCP to address stent.  She will also have CTA pancreas, 
ordered by ERCP team.  They will follow up with her and 
regarding biopsy results.

# Leg swelling:
Minimal difference on L side.  ___ negative for DVT

#Hypothyroidism/depression: continued home meds.

#Hypertension: SBP up to 160s since arrival. No prior dx of 
essential HTN. Will continue to follow for now.  PCP follow up

 
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine 75 mg PO DAILY 
2. Levothyroxine Sodium 100 mcg PO DAILY 

 
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO DAILY 
2. Venlafaxine XR 75 mg PO DAILY 
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days 
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day 
Disp #*6 Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
CBD stricture
Hypothyroidism
Depression

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

 
Discharge Instructions:
You were admitted for ERCP and were found to have a stricture in 
your common bile duct.  You will need to return for another 
procedure to have your stent removed.  You will also need to 
schedule a CT scan of your liver and pancreas.

Please call the radiology dept to schedule this test ASAP: ___.  You will be called with the results of your biopsy 
and for follow up with the GI team.
 
Followup Instructions:
___

{'fogginess': ['Major depressive disorder', 'single episode', 'unspecified'], 'elevated LFTs': ['Obstruction of bile duct', 'Other specified abnormal findings of blood chemistry'], 'dark urine': ['Obstruction of bile duct'], 'tan colored stool': ['Obstruction of bile duct'], 'headaches': ['Major depressive disorder', 'single episode', 'unspecified'], 'bloated abdomen': ['Major depressive disorder', 'single episode', 'unspecified']}