Doc: Kailin Cheng surgery part2

Kailin Cheng

H&P #2

Rotation 9 – Surgery

Location: New York Presbyterian Queens

Date: 11/30/2019

CC: biliary ductal dilation on CT

HPI: 72 y/o male w/PMH HTN, seizures, HLD and type 2 diabetes was admitted for positive klebsiella pneumonie on blood culture done 3 days ago in the ED (11/27). Initially pt presented to the ED c/o fever and chills for 4 days. Pt reported decrease appetite, generalized weakness, nausea without vomiting, subjective fever, and nonproductive cough. He denied abdominal pain, chest pain, SOB, headache, dizziness, diarrhea, dysuria, recent weight change, recent medication change, history of gallbladder stones, alcohol use, being around sick contact, recent traveling, or ever having an endoscopy in the past. His vitals on the ED was febrile (39.4 rectally), HR (85-100), normotensive (106/66), RR 16, oxygen saturation of 90 -95% in room air. CT of abdomen/pelvis showed extrahepatic biliary dilatation with non-specific gallbladder wall thickening, dilated common bile duct of 1.2cm, but no stone visualized and the head CT showed no acute findings. Patient refused admission and left AMA, he was started on ceftriaxone and Flagel.

Differential Diagnosis:

– Cholangitis → CBD dilation, klebsiella bacteremia, fever and chills, nausea, elderly

– Cholecystitis → CDB dilation, gallbladder wall thickening, elderly, nausea, decreased oral intake

– Bacteremia → gram-negative bacteremia, abrupt onset of fever and chills, neutrophilia, leukocytosis

– Hepatic abscess → fever and chills, positive blood culture – klebsiella, Leukocytosis,

– Acute pancreatitis → fever, abdominal distention, nausea, weakness, leukocytosis, and decreased oral intake

– Malignancy (pancreatic) → risk factors – former smoker, diabetic, elderly; Glycosuria, hyperglycemia; CT did not detect a mass

PMH:

– Chronic subdural hematoma collection on Keppra (2019), f/u by neurology

– HTN

– Type 2 diabetes

– History of seizure

– Hyperlipidemia

Immunizations: up to date

Past surgical hx & Past hospitalizations:

– “kidney stone surgery” unknown date

Medication:

– Hyzaar 50 mg-12.5 mg PO, 1 tab, once a day -Indication: HTN

– Metoprolol succinate 25 mg PO, extended release, 1 tab, once a day -Indication: HTN

– Acetaminophen 325 mg PO, 2 tab(s) every 6 hours, As needed, Pain -Indication: Headache

– LevETIRAcetam 500 mg PO, 1 tab, 2 times a day -Indication: Seizure Prophylaxis

– Invokana 300 mg PO, 1 tab, once a day -Indication: DM

– Januvia 100 mg PO, 1 tab, once a day -Indication: DM

– MetFORMIN 500 mg PO, 1 tab, 3 times a day -Indication: DM

– Lipitor 40 mg PO, 1 tab, once a day -Indication: HLD

– Docusate-Senna 50 mg-8.6 mg PO, 1 tab, once a day -Indication: Constipation

Allergies: No known drug, food, or environmental allergies

Family history: Denies Pertinent Family History

Social History:

– Pt lives at home with his family

– Occupation – retired

– Habits – former smoker, denies alcohol and illicit drug use

– Diet – diabetic diet

– Functional Status – independent in ADLs, uses a cane for ambulation

ROS

Constitutional– reports generalized weakness; denies loss of appetite, fever, chills or night sweats

Skin– Denies rashes, dryness, pruritis, or jaundice.

Head– Denies headaches, dizziness, or syncope

Eyes– Denies vision changes or pain

Ears– Denies tinnitus or changes in hearing

Nose– Denies congestion or rhinitis. No epistaxis.

Mouth/Throat– Denies throat soreness and dryness. No oral sores or dysphagia.

Neck– Denies pain or swelling.

Pulmonary System: Denies SOB, DOE, orthopnea, cough, wheezing, hemoptysis, cyanosis or PND

Cardiovascular System: Denies CP, palpitations, irregular heartbeat, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal System: Denies abdominal pain, acid reflux, change in appetite, unintentional weight loss, abdominal distention, nausea, vomiting, dysphagia, pyrosis, eructations, constipation, diarrhea, hemorrhoids

Genitourinary System: Denies dysuria, flank pain, urinary frequency, urinary urgency, nocturia, oliguria, polyuria, hematuria, incontinence or awakening at night to urinate

Endocrine: denies cold intolerance, heat intolerance, polydipsia, polyphagia, polyuria

Nervous System: Reports occasional headaches and taking seizure medication; denies loss of consciousness, sensory disturbances, ataxia, weakness, loss of strength or change in cognition/mental status/memory

Musculoskeletal System: Denies muscle/joint pain, deformity/swelling, redness or arthritis

Peripheral Vascular System: Denies varicose veins, intermittent claudication, coldness or trophic changes, peripheral edema or color change

Hematologic System: Denies easy bruising or bleeding, lymph node enlargement, history of DVT/PE and hx of blood transfusions

Psychiatric: Denies anxiety, depression/sadness, obsessive/compulsive disorder or seeing a mental health professional

Physical Exam

General – Pt is AOx3, looks stated age, appears well-developed and well-nourished. He does not seem to be in distress but appears uncomfortable in bed.

Vitals –

Tc: 36.5 Tmax: 36.9 @ 30 Nov

HR: 79 (65 – 99)

BP: 101/64 (93/56 – 118/63)

RR: 15 (15 – 20)| SpO2: 97% (94% – 100%) Room Air

Wt: 76.1kg (11/30/19), Ht: 170 cm, BMI: 26.3

Skin – Icteric; warm and moist, good turgor, no lesions/scars/tattoos noted

Hair – average quantity and distribution

Nails – no clubbing, capillary refill <2 sec throughout

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

Eyes – sclera icteric, symmetrical OU, no evidence of strabismus/exophthalmos/ptosis, conjunctiva & cornea clear, PERRL, no nystagmus

Ears – symmetrical and normal size, no evidence of lesions/masses/trauma on external ears, no discharge in external auditory canals AU

Nose – symmetrical, no obvious masses/lesions/deformities/trauma/discharge, nares patent bilaterally/nasal mucosa pink & well hydrated, no discharge noted, septum midline without lesions/deformities/injection/perforation, no evidence of foreign bodies

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

Lips – pink, moist, no evidence of cyanosis/lesions, non-tender to palpation

Teeth – good dentition, no obvious dental caries noted

Tongue – pink, well papillated, no masses/lesions/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/bruits noted bilaterally, no palpable adenopathy noted

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

Lungs – clear to auscultation and percussion bilaterally

Heart – Regular sinus rate, rhythm, no murmurs, rubs or gallops

Abdomen – appears distended, no evidence of scars, striae, caput medusae, abnormal pulsations, or masses, BS present in all 4 quadrants, soft, no tenderness to palpation, no rebound or guarding, tympanic

Peripheral Vascular – skin normal in color and warm to touch in upper and lower extremities b/l, no calf tenderness b/l, equal in circumference, no palpable cords/varicose veins b/l, no cyanosis, clubbing or edema noted b/l

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.

Labs/Imaging

CBC & differential → neutrophilia, leukocytosis, mild anemia, thrombocytopenic & lymphocytopenia

Result                     11/27  11/30 -14:46 12/1-03:22    12/01-21:43  12/2-06:38  Ref Range

WBC                     11.62H12.52 (H)     10.10            10.03            9.50              4.5 – 11.0 K/mcL

HGB                      14.0    13.0 (L)        11.1 (L)        11.3 (L)        11.2 (L)          13.5 – 17.5 gm/dL

HCT                      41.4    38.2 (L)        32.8 (L)        32.8 (L)        32.8 (L)          41.0 – 53.0 %

MCV                      90.4    89.0              88.9              88.2              88.6              80.0 – 100.0 fL

PLT                       131L   74 (L)           70 (L)           87 (L)           86 (L)           130 – 400 K/mcL

Neutrophil %          90H    89.0 (H)        83.9 (H)        78.0 (H)        83.0 (H)          40.0 – 70.0 %

Bands                              4%                                   9%               4%

Lymphocyte %       2.8L    3.0 (L)           3.7 (L)          4.0 (L)          6.0 (L)           22.2 – 43.6 %

Monocyte %                     4.0               9.7               7.00              7.00              2.0 – 11.0 %

BMP → hyponatremic, hypokalemic, hypochloremia, hyperglycemic, hypercalcemic, hypermagnesemia, hypophosphatemia

Result                     11/27 11/30 -14:46 12/1-03:22    12/2-06:38    12/3-06:03  Ref Range

Sodium                   133L   129 (L)         137               137               138               136 – 145 mmol/L

Potassium               3.6     3.0 (L)           3.4 (L)          3.5               3.8               3.5 – 5.1 mmoL/L

Chloride                  92L     90 (L)           103               103               104               98 – 108 mmol/L

CO2                       23      24                20                22                22                22 – 29 mmol/L

Glucose                  219H  232 (H)         158 (H)         195 (H)         160 (H)          74 – 110 mg/dL

BUN                       33.9H 39.5 (H)        41.5 (H)        30.1 (H)        16.2              6 – 23 mg/dL

Creatinine               1.25    1.17              1.14              0.94              0.79              0.70 – 1.20 mg/dL

Calcium                  8.6     7.4 (L)          6.5 (L)           6.9 (L)           6.9 (L)           8.6 – 10.0 mg/dL

Anion Gap              18H    15                14                12                12                8 – 16 mEq/L

Magnesium             –         2.8H             2.8                2.5                2.2                1.3 – 2.1 mEq/L

Phosphate              –         2.1L             2.2                1.6                1.4                2.7 – 4.5 mEq/L

LFT → all abnormal, hypoalbuminemia, hypoproteinemia, hyperbilirubinemic, elevated alkaline phosphatase, raised alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Result                     11/27  11/30 -14:46 12/1-03:22    12/2-06:38    12/3-06:03  Ref Range

Albumin                  4.1     3.2 (L)          2.5 (L)          2.4 (L)          2.3 (L)           3.5 – 5.2 g/dL

Total Protein           7.2     6.0 (L)           4.8 (L)          4.9 (L)          4.9 (L)           6.6 – 8.7 g/dL

Total Bilirubin          1.1    2.6 (H)          2.5(H)           1.1               1.3(H)           0.0 – 1.2 mg/dL

Direct Bilirubin         0.5H   2.2 (H)          2.4 (H)          0.9 (H)          0.9 (H)          0.0 – 0.3 mg/dL

ALK PHOS              85      240 (H)         221(H)          239 (H)         241(H)          40 – 129 U/L

ALT                        76H    181 (H)         203 (H)         196 (H)         241 (H)          0 – 41 U/L

AST (SGOT)           26      109 (H)         119 (H)         83 (H)           38                5 – 40 U/L

Lipase                    58      –                   183 (H)         –                   –                   13 – 60 U/L

COAG

PT: 13.3/ PTT 31.4/ INR 1.13 [11/27 @ 19:06] [10.0-13.0 sec, 25.0-35.0 sec, 0.87-1.13]

PT: 12.1 / PTT: 29.1 / INR: 1.05 [12/01 @ 03:22]

UA 11/27

yellow color appears clear, glucose is over 1000, negative bilirubin, specific gravity was 1.032 bit high (1.010-1.030), trace of ketones, moderate blood, pH is 5.0, urine protein 30.

Urine Cx

Negative bacteria, RBC 13 elevated, negative WBC, squamous epith cells, hyaline cast

Procalcitonin = 24.29 – bacterial process highly likely, Abx strongly recommended

11/30/19 CXR: Probable bibasilar atelectasis, and possibly small left pleural effusion. (unremarkable)

11/30/19 CTA/P: Extrahepatic biliary ductal dilatation. Nonspecific gallbladder wall thickening. Again, visualized are findings of polycystic liver and kidney disease. Nonobstructing left renal calculi. Small bilateral pleural effusions.

11/30 US abdomen:

MEASUREMENTS: CBD:   9 mm, RIGHT KIDNEY: 14.8 cm; LEFT KIDNEY:  15.9 cm

SPLEEN: 11.8 cm, LIVER is normal in echogenicity. Multiple hepatic cysts are visualized.

GALLBLADDER: Nonspecific gallbladder wall thickening. No gallstones or gallbladder distention.

BILE DUCTS: Mildly dilated common bile duct without intrahepatic biliary duct dilation.

IMPRESSION: Nonspecific mild gallbladder wall thickening. No gallstones. Mild dilation of the common bile duct without intrahepatic biliary ductal dilation. Remonstrated are findings of polycystic liver and kidney disease.

 

12/2 repeat CT a/p:

1. No evidence of pneumoperitoneum.
2. New trace peripancreatic tail fluid collection, which may relate to pancreatitis.
3. Ill-defined hepatic segment 7 centered region of parenchymal hypoattenuation, more conspicuous compared to prior study, concerning for infection versus malignancy.
4. Multiple hepatic hypodense lesions, which may represent cysts/hamartomas.
5. Bilateral polycystic kidneys.
6. Small ascites.
7. Small bilateral pleural effusions.

 

Assessment

72 y/o male w/PMH HTN, seizures, HLD and DM2 admitted for possible cholangitis and klebsiella bacteremia.

 

Hospital Course

11/30 HD #0: unremarkable CXR, Extrahepatic biliary ductal dilatation seen CT abd/pelvis w/contrast, and abdomen US showed nonspecific mild gallbladder wall thickening. No gallstones. ERCP done with removal of one stone, CBD stent placement and sphincterotomy; possible liver abscess vs infected cysts on repeat CT. Pt was on ceftriaxone and Flagyl and now changed to Zosyn

12/01 PPD #1: GI consult, transfer to floor. At 19:00, Pt febrile and diaphoretic 38.2, tachycardic 113, RR 22, BP 179/103, SPO2 89. Nasal cannula given, labs done, Labs: H/H 11.3/32.8, ProBNP 649, repeat CT abd/pelvis showed possible liver abscess or infected cysts.

12/02 PPD #2: NPO for lap cholecystectomy, vitals stable. Hyperglycemic 195, insulin dose increase to 8 units SQ

12/03 PPD #3: NPO for lap cholecystectomy, vitals stable, Schedule for Lap cholecystectomy @10:40. The lab cholecystectomy was put on hold due to concerns about liver abscess seen on the repeat CT. Patient is afebrile and hemodynamically stable and ready for discharge.

 

Plan on admission (11/30)

– Admission to general surgery floor

– Diabetic diet

– IVF hydration

– D/C Ceftriaxone and Metronidazole

– Start on IV Zosyn

– Monitor vital signs

– Follow up LFT, CBC, CMP daily

– Consider cholecystectomy

 

Plan on discharge date 12/03

– Resume diet since patient is passing gas and has multiple BM, does not have abd pain and feel less distended

– Discharge to home with OPAT (outpatient parenteral abx therapy)

– follow up with ID

– CBC w/diff and CMP weekly

– Heparin lock IV for DVT ppx

– Discharge with homecare and consider PT since pt ambulates with assistance and still feels general weakness

– Plan for outpatient cholecystectomy

– Surgical follow up in one week