Abdominal pain right upper quadrant Abdominal pain epigastric Nausea with vomiting Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH] Bipolar disorder unspecified Esophageal reflux Cannabis abuse continuous Other dyschromia Personal history of tobacco use
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Abd Pain
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ with hx of C-section p/w RUQ pain that started suddenly 
two hours ago, one hour after eating a cheeseburger. Pain is 
___ and is RUQ and epigastric. + nausea. No vomiting. A few 
loose stools today. has not had this pain before. no fevers or 
chills, dysuria or flank pain. Denies recent acetaminophen, 
EtOH. Did have a tooth pulled a few days ago and has been taking 
amoxicillin.  
Of note, she reports going to the ___ ED ~1 month 
ago for abdominal pain, which she describes as esophageal 
discomfort after eating, and was given a medication for 1 week 
(she is unclear what)  
 
In the ED, initial VS were: 98.4 88 111/60 20 99% A RUQ US was 
obtained given concern for billiary colic and did not show any 
obstruction of gallbladder distention. Surgery was consulted as 
well and did not feel that her exam or labs were consistant with 
an acute biliary obstruction, but did raise concern for ulcer 
disease. LFTs were returned with a transaminitis in an AST>ALT 
pattern and no evidence of AP or bili elevation. She was given 
analgesics and anti-emetics and admitted to medicine. 
. 
VS on transfer: 72 118/52 18 99%. Currently, she is in NAD, 
feeling somewhat better than before.  
.
After arrival to the floor, the patient reported improved 
symptoms. However, repeat LFT's were noted to be even more 
elevated. Broad work-up was started for various causes of 
hepatitis. However, prior to results being available, she left 
AGAINST MEDICAL ADVICE (see hospital course below). After this, 
she was contacted at home and agreed to return to the hospital 
to complete work-up. She was directly readmitted.
 
Past Medical History:
-Bipolar with several past psych admissions  
-hx of chlamydia infection  
-hx of panic disorder  

 
Social History:
___
Family History:
Adopted, she does not know her biological family
 
Physical Exam:
Admission Exam:
PHYSICAL EXAM:  
VS: 98.8 72 118/52 18 99%  
GENERAL: well appearing, NAD, AA female  
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM  
NECK: supple, no LAD, JVD:  
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, 
no accessory muscle use  
HEART: RRR, no MRG, nl S1-S2  
ABDOMEN: normal bowel sounds, soft, mildly tender in 
epigastrum/RUQ, non-distended, no rebound or guarding, no masses 
 
EXTREMITIES: no edema, 2+ pulses radial and dp  
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength 
___ throughout, sensation grossly intact throughout, DTRs 2+ and 
symmetric  
.
Discharge Exam:
T 98 BP 90-100/50-70 HR ___ RR 16 O2 Sat 100% RA
GENERAL: well appearing, NAD 
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM  
NECK: supple, no LAD, JVD:  
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, 
no accessory muscle use  
HEART: RRR, no MRG, nl S1-S2  
ABDOMEN: normal bowel sounds, soft, mildly tender in RUQ, 
non-distended, liver edge palpable just below the R costal 
margin
EXTREMITIES: no edema, 2+ pulses radial and dp  
NEURO: awake, A&Ox3, CNs II-XII grossly intact, non focal
PSYCH: Affect approproate, calm, goal directed, speech not 
pressured

 
Pertinent Results:
Labs:

___ 07:20PM BLOOD WBC-8.5 RBC-4.28 Hgb-13.0 Hct-40.7 MCV-95 
MCH-30.5 MCHC-32.1 RDW-13.1 Plt ___
___ 07:10AM BLOOD WBC-5.2 RBC-4.20 Hgb-13.0 Hct-40.9 MCV-97 
MCH-31.0 MCHC-31.8 RDW-12.9 Plt ___
___ 06:40AM BLOOD WBC-4.0 RBC-4.12* Hgb-12.5 Hct-39.1 
MCV-95 MCH-30.4 MCHC-32.0 RDW-13.2 Plt ___
___ 07:20PM BLOOD Neuts-73* Bands-0 ___ Monos-5 Eos-0 
Baso-1 ___ Myelos-0
___ 07:10AM BLOOD Neuts-66 Bands-4 ___ Monos-4 Eos-0 
Baso-1 ___ Metas-1* Myelos-0
___ 07:10AM BLOOD ___ PTT-31.7 ___
___ 07:10AM BLOOD Plt Smr-NORMAL Plt ___
___ 01:15PM BLOOD ___ PTT-34.1 ___
___ 06:40AM BLOOD ___ PTT-34.1 ___
___ 07:20PM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-141 
K-3.6 Cl-101 HCO3-29 AnGap-15
___ 07:10AM BLOOD Glucose-78 UreaN-11 Creat-0.8 Na-138 
K-3.9 Cl-105 HCO3-27 AnGap-10
___ 06:40AM BLOOD Glucose-101* UreaN-7 Creat-0.8 Na-140 
K-4.0 Cl-108 HCO3-24 AnGap-12
___ 07:20PM BLOOD ALT-169* AST-293* AlkPhos-64 TotBili-0.4
___ 07:10AM BLOOD ALT-876* AST-750* LD(___)-607* 
CK(CPK)-237* AlkPhos-75 TotBili-0.6
___ 01:15PM BLOOD ALT-760* AST-542* LD(LDH)-474* 
CK(CPK)-306* AlkPhos-90 TotBili-0.6
___ 06:40AM BLOOD ALT-434* AST-180* AlkPhos-71 TotBili-0.4
___ 07:20PM BLOOD Lipase-56
___ 07:20PM BLOOD Albumin-4.6
___ 07:10AM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.3 Mg-2.0
___ 01:15PM BLOOD Iron-112
___ 06:40AM BLOOD Albumin-4.0 Calcium-9.2 Phos-2.9 Mg-2.0
___ 01:15PM BLOOD calTIBC-342 Ferritn-151* TRF-263
___ 07:10AM BLOOD TSH-1.8
___ 07:10AM BLOOD Free T4-1.2
___ 07:10AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-PND 
HAV Ab-NEGATIVE IgM HAV-NEGATIVE
___ 08:33AM BLOOD AMA-PND Smooth-PND
___ 08:33AM BLOOD ___
___ 07:10AM BLOOD IgG-1031
___ 01:15PM BLOOD HIV Ab-NEGATIVE
___ 07:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:10AM BLOOD HCV Ab-NEGATIVE
___ 01:15PM BLOOD CERULOPLASMIN-PND
.
RUQ Ultrasound:
The liver shows no evidence of focal lesions or textural 
abnormality.  There is no evidence of intrahepatic or 
extrahepatic biliary dilatation.  The CBD measures 3 mm.  The 
main portal vein is patent. The gallbladder is normal without 
evidence of stones or gallbladder wall thickening.  Limited 
views of the right kidney are unremarkable.   
  
IMPRESSION: Normal right upper quadrant ultrasound. No 
gallstones or evidence of acute cholecystitis. 

 
Brief Hospital Course:
Primary Reason for Admission: Ms ___ is a ___ y/o woman with no 
significant past medical history presenting with acute onset RUQ 
pain and transaminitis after eating a cheeseburger.
.
Active Problems: 
.
# Acute Hepatitis: RUQ ultrasound was unremarkable without e/o 
cholecystitis or choledocolithiasis. There was no portal vein 
thrombus. Acetaminophen level was 0 on admission. No recent EtOH 
use, EtOH level also 0. Denies recent IV or intranasal drug use, 
though does have several tattoos. Serum and Urine tox screens 
were negative on admission. HIV negative. Autoimmune and 
infectious workup pending at time of d/c. Would note that she 
was adopted with known psychiatric comorbidities, which raises 
concern for Wilsons Disease. Ceruloplasmin also pending at time 
of d/c. Fe studies unremarkable. LFT's peaked and began to 
down-trend. At the time of d/c, her abd pain had resolved and 
she was tolerating a normal diet. 

# Psych: Ms ___ was extremely volatile during her admission. 
Social work was consulted and attempted to reassure the patient. 
This seemed to make things worse, and Ms ___ left the floor 
repeatedly on the morning of HD #1. Per RN, Ms ___ was 
overheard threatening to leave AMA and "take a bottle of pills." 
At that time, Psych was urgently consulted, though the patient 
would not cooperate with psych interview. She was noted to be 
future oriented and was felt to not be an acute suicide risk. 
After meeting with Psych, Ms ___ left the hospital AMA before 
the medical team was able to speak with her further. We then 
called Ms ___ and convinced her to return to ___ and she was 
directly readmitted. Per psych, she does not need 1:1 sitter or 
section and is safe for d/c from a psych perspective. 

# GERD: Ms ___ endorsed classical GERD symptoms, for which she 
was started on Omeprazole. EGD for similar symptoms in ___ was 
WNL. She should f/u with her PCP for possible ___ Pylori testing 
and ongoing management of GERD. 
.
Transitional Issues:
Code: Full 
HCP: None
# Hepatitis: ___ f/u for Acute Hepatitis and GERD
 
Medications on Admission:
-Implanon 68 mg subdermal implant  
-lorazepam 0.5 mg BID (not currently taking)  
- amoxicillin (unknown dose)  

 
Discharge Medications:
1. Omeprazole 40 mg PO DAILY 
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 
Capsule Refills:*0
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30 
Capsule Refills:*0
2. IMPLANON *NF* (etonogestrel) ___ischarge Disposition:
Home
 
Discharge Diagnosis:
Primary Diagnosis:
Acute Hepatitis
Secondary Diagnosis:
GERD

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

 
Discharge Instructions:
Dear Ms ___, 

It was a pleasure caring for you at the ___ 
___. You were admitted for abdominal pain. We found 
that your liver function tests were abnormal. For this, we 
performed blood tests to help us understand what caused the 
damage to your liver. Many of these tests are still pending. 
Thankfully, your liver function has improved markedly over the 
course of your hosptial stay and you are now safe to go home. It 
will be importnat to follow up with your PCP and with the 
doctors at the ___ at ___. 

We also started you on a medication for acid reflux. You should 
take this every day. If your reflux symptoms to not improve, you 
should mention this to your PCP and liver doctor, as you may 
need another upper endoscopy. Thank you for allowing us to 
participate in your care. 
 
Followup Instructions:
___

{'Abd Pain': ['Acute Hepatitis', 'GERD'], 'epigastric': ['Acute Hepatitis', 'GERD'], 'nausea': ['Acute Hepatitis', 'GERD'], 'transaminitis': ['Acute Hepatitis'], 'bipolar': ['Bipolar disorder'], 'esophageal reflux': ['GERD'], 'cannabis abuse': ['Cannabis abuse'], 'dyschromia': ['Other dyschromia'], 'tobacco use': ['Personal history of tobacco use']}