DOC 1- R8 H&P 1 -Kailin Cheng

H&P #1

Rotation 8 – Emergency Medicine

Location: Brookdale Hospital Emergency Department

Date: 10/21/19 Time: 7:22AM

CC: Abdominal pain x4 days

HPI

66 year old African American female with PMH HTN, HLD, and history of EtOH abuse presents to the ED from home c/o RUQ abdominal pain x 4 days. Patient reports her symptoms worsened overnight, which awoke her from her sleep; she describes the pain as intermittent, sharp, 5/10, localized to the RUQ radiating to the RLQ, and without any provoking factors. Patient also reports nausea and two episodes of emesis, which appeared to be only the food she ate this morning. She took acetaminophen without alleviation. Her last bowel movement was this morning. Patient reports she was here in the ED four days ago for similar symptoms, an ultrasound of the abdomen showed fatty infiltration of the liver with cholelithiasis. Patient denies fever, chills, chest pain, vaginal discharge or urinary incontinence, recent antibiotic use, recent travel or other person around her with similar symptoms. No history of prior abdominal surgeries.

Differential Diagnosis

1. Cholelithiasis → she has risk factors (female, fat, fertile, over 40), US abdomen 4 days ago showed stones, RUQ pain, nausea and vomiting
2. Gallstone-induced pancreatitis → gallstones and history of alcohol abuse, accompany with nausea and vomit

PMH

• Alcoholism x35 years
• Hypertension x19 years
• Hypercholesterolemia x11 years

Immunizations

• Up to date
• Flu vaccine this year

Past surgical hx

• C-Section procedure in 1991

Past hospitalizations

None

Medication

1. amlodipine (NORVASC) 5 mg tablet, take 1 tablet PO daily for ↑BP
2. aspirin (ASPIR-LOW) 81 MG enteric coated tablet, take 1 tablet PO daily for circulation
3. atorvastatin (LIPITOR) 40 mg tablet, take 1 tablet PO At Bedtime for hypercholesterolemia
4. Calcium-Vitamin D 600-200 MG-UNIT per tablet, take 1 tablet PO BID for: prophylaxis osteoporosis
5. losartan (COZAAR) 100 mg tablet, take 1 tablet PO daily for ↑BP
6. metoprolol (TOPROL XL) 100 mg tablet, take 1 tablet PO daily for ↑BP
7. multivitamin (MULTIPLE VITAMINS) TABS, take 1 tablet PO daily

Allergies

Metronidazole à rash

Family history

Mother → died from COPD, 85

Father → unknown

Grandfather (maternal) → pt doesn’t know

Grandmother (maternal) → pt doesn’t know

Grandfather (paternal) → pt doesn’t know

Grandmother (paternal) → pt doesn’t know

4 children → all alive and healthy

Social History

Patient is currently retired living with her children, used to work in sales department. Patient is not married and she is not sexually active. Patient reports she quit smoking a few months ago x15 pack years. Patient reports alcohol abuse. Denies illicit drug use. She does not have a specific diet or exercise regimen.

ROS

General

• denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats

Skin, hair and nails

• denies change in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution

Head

• denies HA, vertigo, or head trauma

Eyes

• does not remember date of last eye exam; denies visual disturbance, lacrimation, photophobia, or pruritus

Ears

• denies deafness, pain, discharge, tinnitus, or use of hearing aids

Nose/Sinuses

• denies epistaxis or obstruction, congestion and rhinorrhea

Mouth and throat

• does not remember date of last dental exam; denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, or use of dentures

Neck

• denies localized swelling/lumps, or stiffness/decreased range of motion

Breast

• denies lumps or pain

Pulmonary System

• denies SOB, hemoptysis, cyanosis, PND, DOE, orthopnea, cough and wheezing

Cardiovascular System

• reports HTN taking medication; denies palpitations, CP, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal System

• reports abdominal pain, nausea and vomiting; denies change in appetite, intolerance to specific foods, dysphagia, pyrosis, flatulence, eructation, constipation, diarrhea, change in bowel habit, hemorrhoids, or melena

Genitourinary System

• denies urinary frequency, urinary urgency, flank pain, nocturia, oliguria, polyuria, dysuria, incontinence, hesitancy or dribbling

Nervous System

• denies HA, seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory, or weakness

Musculoskeletal System

• denies muscle/joint pain, deformity/swelling, redness, or arthritis

Peripheral Vascular System

• denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color change

Hematologic System

• denies easy bruising or bleeding, hx of blood transfusions, lymph node enlargement, or history of DVT/PE

Endocrine System

• denies polyuria/polydipsia/polyphagia, heat or cold intolerance, goiter, excessive sweating, or hirsutism

Psychiatric

• denies anxiety, depression/sadness, obsessive/compulsive disorder, or seeing a mental health professional

Physical Exam

Patient is alert and oriented x3, she appears her stated age, well-nourished, medium build and well-developed w/ appropriate hygiene and motor activity. Pt is laying down in bed and looks uncomfortable but not in distress.

Vitals

BP  144/88, HR  66, RR  18, Temp  36.4 °C (97.6 °F), SpO2  100%

Wt  172 lb, Ht  5′ 4″, BMI  29.6

Skin:           warm and moist, good turgor; nonicteric, no lesions noted, no scars, or tattoos

Hair:          average quantity and distribution

Nails:          no clubbing, capillary refill <2 sec throughout

Head:          normocephalic, atraumatic, non-tender to palpation throughout

Eyes:          symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear; visual fields full OU; PERRL; EOMs full with no nystagmus

Ears:          symmetrical and normal size; no evidence of lesions/masses/trauma on external ears. No discharge/foreign bodies in external auditory canals AU. TM’s pearly white/intact with light reflex in normal position AU

Nose: symmetrical, no obvious masses/lesions/deformities/trauma/discharge. Nares patent bilaterally/nasal mucosa pink & well hydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions/deformities/injection/perforation. No evidence of foreign bodies

Sinuses: non-tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses

Lips: pink, moist; no evidence of cyanosis or lesions. Non-tender to palpation

Mucosa: pink; well hydrated. No masses; lesions noted. Non-tender to palpation. No evidence of leukoplakia

Palate: pink; well hydrated. Palate intact with no lesions/masses/scars. Non-tender to palpation

Teeth: Good dentition, no obvious dental caries noted

Gingivae: pink; moist. No evidence of hyperplasia/masses/lesions/erythema or discharge. Non-tender to palpation.

Tongue: pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation

Oropharynx: well hydrated; no evidence of exudate/masses/lesions/foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pink, no edema, lesions

Neck: trachea midline. No masses, lesions, scars, pulsations noted. Supple, non-tender to palpation. Full ROM; no stridor noted. 2+ Carotid pulses, no thrills or bruits noted bilaterally, no palpable adenopathy noted

Thyroid: non-tender, no palpable masses, no thyromegaly

Chest: symmetrical, no deformities, no evidence trauma. No use of accessory muscles noted. Lat to AP diameter 2:1. Non-tender to palpation.

Lungs: clear to auscultation and percussion bilaterally, chest expansion and diaphragmatic excursion symmetrical, tactile fremitus intact throughout, no adventitious sounds

Heart: Carotid pulses are 2+ bilaterally without bruits. S1 and S2 are normal. There are no murmurs or extra heart sounds

Abdomen: lower midline scar from c-section, soft, distended, she exhibits significant tenderness to palpation in the RLQ and RUQ, positive murphy’s sign, BS present in all 4 quadrants. No evidence of masses, striae, caput medusae or abnormal pulsations. No bruits noted over aortic/renal/iliac/femoral arteries. No evidence of organomegaly. No evidence of rebound tenderness. No CVAT noted bilaterally

Peripheral Vascular: Skin normal in color and warm to touch upper and lower extremities bilaterally. No calf tenderness bilaterally, equal in circumference. Homan’s sign not present bilaterally. No palpable cords or varicose veins bilaterally. No palpable inguinal or epitrochlear adenopathy. No cyanosis, clubbing/edema noted bilaterally

Mental Status: Alert and oriented to person, place and time. Memory and attention intact. Receptive and expressive abilities intact. Thought coherent. No dysarthria, dysphonia or aphasia noted

Motor/Cerebellar: Full active/passive ROM of all extremities without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, tremors or fasciculations. Strength equal and appropriate for age bilaterally (5/5 throughout). No asterixis

Labs

CBC

WBC                                                                        8.00

RBC                                                                         3.99

HGB                                                                         11.2 ↓

Hematocrit                                                               33.8 ↓

MEAN CORPUSCULAR VOLUME                             84.8

MEAN CORPUSCULAR HEMOGLOBIN                     28.1

MEAN CORPUSCULAR HEMOGLOBIN CONC                    33.1

RED CELL DISTRIBUTION WIDTH                            14.8

MEAN PLATELET VOLUME                                      8.5     fL

Platelets                                                                   348     10×3/uL

Neutrophils Auto                                                     77.5 ↑

          Lymphocytes Auto.                                                           12.5 ↓

Monocytes Auto                                                        8.3     %

Eosinophils Auto.                                                      1.0     %

Basophils Auto.                                                         0.7     %

Neutrophils Absolute                                                           6.20          10×3/uL

Lymphocytes Absolute                                           1.00 ↓ 10×3/uL           

Monocytes Absolute                                                            0.70          10×3/uL

Eosinophils Absolute                                                           0.10          10×3/uL

Basophils Absolute                                                    0.10    10×3/uL

Estimated Glomerular Filtration Rate

GFR MDRD Non Af Amer                                          15

GFR MDRD Af Amer                                                 18

Hepatic function panel

Albumin                                                                    4.2     g/dL

Bilirubin, Total                                                           1.0     mg/dL

        Bilirubin, Direct                                                       0.5 ↑   mg/dL           

Alkaline Phosphatase                                                          75.0    U/L

Protein, Total                                                             8.1     g/dL

ALT                                                                          17      U/L

AST                                                                         46 ↑    U/L      

Lipase                                                                    134     U/L

Basic metabolic panel

Glucose                                                                   98      mg/dL

 BLOOD UREA NITROGEN                                      31.0 ↑ mg/dL           

           Creatinine                                                               3.11 ↑ mg/dL           

Sodium                                                                    137     mEq/L

 Potassium                                                              5.8 ↑   mEq/L           

CHLORIDE                                                              100     mEq/L

CO2                                                                        27      mEq/L

Anion Gap                                                               10.00  mEq/L

Anion gap with K                                                      15.80  mmoL/L

Calcium                                                                   9.7     mg/dL

 Protime-INR

Prothrombin Time                                                      11.8    Sec

INR                                                                          1.05

Troponin I                                                                 0.019  ng/mL

PTT                                                                          27.8    sec

 CT abd/pelvis without contrast

Gallbladder is abnormal thick wall and contains small calcified calculi. Mild infiltration of fat in right upper quadrant consistent with acute cholecystitis.

Differential Diagnosis

1. Acute Cholecystitis → RUQ pain, positive Murphy’s sign, mild elevation of bilirubin, aspartate aminotransferase (AST)
2. Biliary Colic → RUQ pain, nausea and vomiting, sonography showed stones
3. Acute Appendicitis → sharp pain in RLQ and RUQ, nausea and vomiting

Assessment

66 year old African American female with PMH HTN, HLD, and history of EtOH abuse presents to the ED c/o RUQ abdominal pain x 4 days. Vital signs are within the normal limits. At this time, patient is well-appearing, significant tenderness to palpation in the RUQ and RLQ, positive murphy’s sign. CT abd/pelvis showed gallbladder wall thickening and mild infiltration of fat in the RUQ. Finding are most consistent with acute cholecystitis.

Management/Plan

• Admit to surgery
  • OR for laparoscopic cholecystectomy
  • NPO, only IV fluids
  • IV antibiotics – piperacillin/tazobactam 3.375 g q6h
  • IV analgesia – start with NSAIDs, then morphine if no significant improvement
  • IV antiemetics – ondansetron 4mg IV
• Post-op
  • Continue pain reliver – NSAIDs PO as needed
  • Continue with current medication
    • Hypertension – amlodipine 5 mg, losartan100 mg, metoprolol100 mg
    • Hypercholesterolemia – atorvastatin 40 mg
    • Anticoagulants – aspirin 81mg
    • Nutritional supplement – Calcium-Vitamin D 600-200 MG-UNIT & multivitamin

Patient Education

Acute cholecystitis is when the gallbladder gets inflamed usually because of gallstones blocking the cystic duct (tube the connects the gallbladder to other ducts ending into the duodenum). It may start with sudden pain in the upper belly, fever, nausea, and vomiting. Ultrasound of the abdomen can help us see signs of gallbladder inflammation and or stones. In your ultrasound, it showed gallstones inside the gallbladder.

The treatment for cholecystitis is surgical removal of the gallbladder. You are being admitted to surgery, you should not eat or drink anything now, IV fluids will be given to you. A doctor will also come to put a flexible tube through the nose into the stomach, to remove any food your stomach may have and keep it empty to minimize fluid retention in the intestine during the surgery. This is done to prevent complications.

Antibiotics and pain relievers will be given to you by IV

The surgery will be laparoscopic, where three small incisions will be made in the abdomen. You will be under general anesthesia (you will be sleeping through the surgery). The surgery should take a couple hours and based on your after surgery response, you can be discharged on the same day.

Pain reliever will be prescribed and a follow-up appointment will be scheduled.

Return to the ED, if you have any sign of fever or unbearable abdominal pain.