Calculus of bile duct without mention of cholecystitis without mention of obstruction Leukemic reticuloendotheliosis unspecified site extranodal and solid organ sites Personal history of tobacco use Personal history of antineoplastic chemotherapy Other acquired absence of organ
 
Name:  ___.             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: SURGERY
 
Allergies: 
Morphine
 
Attending: ___
 
Chief Complaint:
RUQ abdominal pain 
 
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___ 
laparoscopic cholecystectomy ___

 
History of Present Illness:
___ s/p C-section ___ presents to the ___ ER after
experiencing an acute onset of RUQ pain after eating last night.
Patient states she ate a steak dinner yesterday evening and
approximately one hour after had an acute onset of sharp, severe
RUQ pain. The pain was constant and associated with nausea but 
no
vomiting. She went an OSH hospital where her pain resolved with
pain medication and was told to follow up with her PCP. After
returning home she had two more episodes of pain which resolved
within an hour. She also reports having another episode of pain 
2
weeks ago in a similar location, but less severe which resolved
after an hour. She denies fevers, vomiting, BRBPR or melena.

 
Past Medical History:
- Hairy cell leukemia (now status post 1 cycle Cladribine)  
- History of diabetes mellitus, untreated /diet controlled .  
- S/p knee and ankle surgeries x ___  
- S/p appendectomy  

 
Social History:
___
Family History:
Her mother is ___ and has thyroid disease and elevated 
cholesterol. Her father is ___ and has coronary artery disease 
and hemochromatosis. Her brother is ___ and well. She has one 
paternal uncle who died in his ___ from an asbestos-related 
cancer. No other family members have cancers or blood disorders. 
 

 
Physical Exam:
Physical Exam:
Vitals: T 97.8 P 80 BP 130/90 RR 16 O2 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, negative ___ sign no
rebound or guarding, normoactive bowel sounds, no palpable 
masses
Ext: No ___ edema, ___ warm and well perfused

 
Pertinent Results:
___  WBC-6.4 RBC-3.96* HGB-11.7* HCT-35.0* MCV-89 MCH-29.7 
MCHC-33.6 RDW-13.3
___  ALT-366* AST-396* AlkPhos-173* Amylase-39 TotBili-2.6* 
DirBili-1.4* IndBili-1.2
___  ALT-342* AST-206* AlkPhos-166* Amylase-34 TotBili-3.2*
___  ALT-249* AST-101* AlkPhos-170* TotBili-1.5
___  ALT-158* AST-49* AlkPhos-144* TotBili-1.0
___  Lipase-29

RUQ (___)
 1. Slightly distended gallbladder, but no evidence of
cholecystitis or cholelithiasis. 
2. Echogenic liver consistent with fatty infiltration; other
forms of liver disease, including more significant hepatic
fibrosis or cirrhosis cannot be excluded on the basis of this
examination. 
3. Mildly enlarged spleen measuring 13.2 cm.

ERCP ___
The major papilla was bulging proximal to the opening. There 
appeared to be two openings to the biliary orifice consistent 
with a possible fistula. 
A sphincterotomy was performed in the 12 o'clock position using 
a sphincterotome over an existing guidewire. There was no 
bleeding. 
The intrahepatics were normal. The CBD was around 7 mm. There 
was a distal CBD filling defect.   The stone was extracted 
successfully using a 9-12 mm stone extraction balloon. An 
occlusion cholangiogram after the bile duct sweeps showed no 
filling defects. There was excellent flow of bile and contrast.

 
Brief Hospital Course:
 The patient was admitted to the ___ service on ___ for right 
upper quadrant pain on elevated LFTs suggestive of 
choledocolithiasis.  She was made NPO and started on 
maintainence IVFs.  Her abdominal pain was well controlled on 
the floor.  Her follow-up LFTs on HD#2 revealed an uptrending 
t-bili from admission (2.6->3.2). Interventional GI was 
consulted and the patient underwent successfully ERCP removal of 
a CBD stone with sphincterotomy on ___.  

 The patient did not exhibit complications from the ERCP and her 
abdominal pain improved significantly following the procedure as 
well.  On HD#3, the patient's LFTs downtrended, most notable for 
a t-bili of 1.5 (from 3.2), along with a decrease in her 
transaminitis.  Given the patient's clinical improvement and 
downtrending LFTs, the decision was made to proceed to 
laparoscopic cholecystectomy, which was performed on ___.  
The procedure was without complication.  The patient's diet was 
advanced on POD#1, and she was tolerating a regular diet upon 
discharge.  She was instructed to follow-up in the ___ clinic in 
2 weeks.                
 
Medications on Admission:
none
 
Discharge Medications:
1. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain 
RX *Endocet 5 mg-325 mg ___ Tablet(s) by mouth every four (4) 
hours Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID 
RX *Colace 100 mg 1 Capsule(s) by mouth twice a day Disp #*14 
Capsule Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
choledocolithiasis 

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

 
Discharge Instructions:
You were admitted to the acute care surgery service with 
choledocolithiasis (a gallstone in you common bile duct).  The 
gallstone was removed by a procedure called an ERCP.  You then 
underwent a laparoscopic cholecystectomy to remove your 
gallbladder without complication.  Below are instructions to 
follow post-operatively: 

Please resume all regular home medications unless specifically 
advised not to take a particular medication.  Also, please take 
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times 
per day, and drink adequate amounts of fluids.  Avoid lifting 
weights greater than ___ lbs until you follow-up with your 
surgeon, who will instruct you further regarding activity 
restrictions.
Avoid driving or operating heavy machinery while taking pain 
medications.
Please follow-up with your surgeon and Primary Care Provider 
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have 
increased pain, swelling, redness, or drainage from the incision 
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical 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 ___ days after surgery.

 
Followup Instructions:
___

{'RUQ pain': ['Calculus of bile duct without mention of cholecystitis'], 'nausea': ['Calculus of bile duct without mention of cholecystitis'], 'elevated LFTs': ['Calculus of bile duct without mention of cholecystitis'], 'hairy cell leukemia': ['Leukemic reticuloendotheliosis'], 'history of diabetes mellitus': ['unspecified site'], 'knee and ankle surgeries': ['extranodal and solid organ sites'], 'appendectomy': ['Personal history of tobacco use'], 'family history of thyroid disease': ['Personal history of antineoplastic chemotherapy'], 'family history of elevated cholesterol': ['Other acquired absence of organ']}