Calculus of bile duct without cholangitis or cholecystitis with obstruction Biliary acute pancreatitis Nonalcoholic steatohepatitis (NASH) Diverticulitis of intestine part unspecified without perforation or abscess without bleeding Encounter for immunization Generalized anxiety disorder Obstructive sleep apnea (adult) (pediatric) Acquired absence of stomach [part of]
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
morphine / Bactrim / Feldene / Celebrex / Naprosyn
 
Attending: ___.
 
Chief Complaint:
abdominal pain
 
Major Surgical or Invasive Procedure:
Uncomplicated ERCP ___
 
History of Present Illness:
___ h/o sleeve gastrectomy with 5d of mailaise, LLQ abdominal 
pain, evolving generalized abdominal pain and fevers and chills 
now diagnosed with acute pancreatitis and diverticulitis.  She 
describes progressively worse now severe abdominal pain 
specifically RUQ and epigastric radiating to back and shoulders 
and LLQ pain.  She was seen in urgent care this weekend w urine 
sent and cipro prescribed.  She came to ___ today 
where she had hypotension and imaging (CT abdomen) and labs 
showed acute pancreatitis and diverticulitis and cholestasis.  
She received IVF and ertapenem    She came to ___ and 
ERCP was performed w sphincterotomy and balloon extraction of 
stones.  

ROS:
fever/chills, mailaise, vomit x1 last week, reduced oral intake, 
some dysuria and frequency, no other change in health in 13pt 
ROS unless described above
 
Past Medical History:
OSA on bipap
NASH
s/p sleeve gastrectomy at ___
arthritis
s/p hysterectomy for endometrial hyperplasia
panniculectomy

Her gallbladder remains after above surgeries

 
Social History:
___
Family History:
mother w colon ca
 
Physical Exam:
98.1 95-105/60 62 99% RA
aox3 attentive and not confused
some scleral icterus
tongue dry
neck supple
face symmetric
clear BS
regular s1 and s2
obese abdomen, bowel sounds present
RUQ++ and epigastric ++ tenderness to palpation
less intense tenderness in LLQ
unable to appreciate if hepatomegaly present
no peripheral edema or rash
did not test gait
speech fluent
mood calm
able to sit up on her own
 
Pertinent Results:
ERCP

Evidence of a sleeve gastrectomy was noted.  
The major papilla was on the rim of a large diverticulum.   
Cannulation of the biliary duct was successful and deep with a 
sphincterotome using a free-hand technique.  
There was a filling defect that appeared like sludge in the 
lower third of the common bile duct.  
There was mild upstream dilation with the CBD measuring 8mm in 
maximal diameter.  
A sphincterotomy was performed in the 12 o'clock position using 
a sphincterotome over an existing guidewire. Minor oozing was 
noted. 
Balloon sweeps were performed of the common bile duct which 
yielded sludge but no obvious stone.  
Further sweeps were performed until no debris was noted.  
Completion occlusion cholangiogram revealed no further filling 
defects. 
10cc epinephrine were injected for hemostasis successfully at 
the major papilla

___ 10:50AM BLOOD WBC-8.0# RBC-4.43 Hgb-12.5# Hct-37.6# 
MCV-85 MCH-28.2 MCHC-33.2 RDW-13.4 RDWSD-41.4 Plt ___
___ 10:50AM BLOOD Neuts-83* Bands-8* Lymphs-5* Monos-4* 
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-7.28* 
AbsLymp-0.40* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*
___ 10:50AM BLOOD Glucose-109* UreaN-15 Creat-0.8 Na-138 
K-4.6 Cl-107 HCO3-23 AnGap-13
___ 10:50AM BLOOD ALT-191* AST-207* AlkPhos-152* 
TotBili-5.8*
___ 10:50AM BLOOD Lipase-3785*
___ 10:50AM BLOOD Albumin-3.1* Calcium-8.9 Phos-2.9 Mg-1.5*
___ 10:52AM BLOOD Lactate-0.8

___ CT Impression
 Fat stranding around pancreas, and second and third portions
 
duodenum. Possibly pancreatitis, possibly duodenitis. Clinical
 
correlation advised.
 
2. Acute mild uncomplicated sigmoid diverticulitis.
 
3. Gallstones, distended gallbladder, possibly reflecting 
fasting
 
state. Clinical correlation necessary. HIDA scan may be 
considered for
 
further evaluation if there is right upper quadrant pain.
 
4. Hysterectomy. Other incidental findings as outlined.

 
Brief Hospital Course:
___ w NASH and s/p sleeve gastrectomy now hospitalized w 
gallstone pancreatitis and acute diverticulitis.  She is now s/p 
ERCP and sphincterotomy for associated choledocolithiasis with 
obstruction.   She has features of early sepsis including 
hypotension as low as ___ responsive to fluids at ___ and 
subjective fevers/chills.  Lactate was 0.8.

#Acute bile duct obstruction, with possible early cholangitis 
due to choledocholithiasis:  She was managed with fluid 
resuscitation and ERCP with stone extraction.  Biliary jaundice 
improved and she tolerated a full diet.  She was instructed to 
f/u with outpatient surgeon for CCY and will do so through PCP. 
She will complete 10day antibiotic course with Cipro/flagyl

# Acute Diverticulitis - clinically resolved, she will complete 
10 days cipro/flagyl

#NASH cirrhosis: followed by liver clinic in past at ___ and 
now by local area hepatologist.  This was clinically stable 
here. 

#OSA: continued CPAP

#Anxiety: diazepam prn

#Possible UTI: I called her PCP's office (___) ___ to inquire about UA and if urine culture results are 
known sent this past ___.  I spoke with RN ___ to review 
results ___ (was given Cipro for UTI) -- UCx multiple 
organisms present, contaminated specimen. 

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 
2. Diazepam 2 mg PO DAILY:PRN anxiety 
3. Ranitidine 150 mg PO DAILY 

 
Discharge Medications:
1. Diazepam 2 mg PO DAILY:PRN anxiety 
2. Ciprofloxacin HCl 500 mg PO Q12H 
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth q12 hr Disp 
#*18 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H 
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day 
Disp #*27 Tablet Refills:*0
4. Ranitidine 150 mg PO DAILY 
5. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Choledocholithiasis
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
You were admitted with biliary duct obstruction due to retained 
gallstones. You underwent successful ERCP with stone removal 
with significant clinical improvement.  You had You tolerated a 
regular diet without pain. You jaundice should continue to 
improve. You understand the recommendation to follow up with a 
surgeon (via PCP ___ for gallbladder removal.  Your 
outside hospital also had suggestion of acute diverticulitis. 
Therefore you should complete a 10day course of antibiotics for 
this as prescribed.
 
Followup Instructions:
___

{'abdominal pain': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'fever/chills': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'malaise': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'vomit': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'reduced oral intake': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'dysuria': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'frequency': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'RUQ++ and epigastric ++ tenderness': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine'], 'less intense tenderness in LLQ': ['Calculus of bile duct without cholangitis or cholecystitis with obstruction', 'Biliary acute pancreatitis', 'Diverticulitis of intestine']}