HISTORY  

Identifying Data: 

Full Name: VR 

Address: Ozone Park, Queens, NY 

Date of Birth: 4/6/1957

Date and Time: 1/13/22 11:30 PM

Location: NYP Queens 

Sex: Male 

Age: 64 

Race: Indian 

Religion: Muslim

Marital Status: Married 

Source of Information: Self  

Reliability: Reliable  

Source of Referral: Self 

Chief Complaint: “abdominal pain” x 3 days

HPI: 

VR is a reliable 64 y/o male Indian male, English-speaking, PMH Hypertension, hyperlipidemia, DM2, no PSH, who presented to the ED complaining of upper quadrant abdominal pain x 3 days. Pt stated the pain came on suddenly when he woke up 3 days ago, is “above the ribs,” constant, aggravated by eating, and occasionally radiates to his chest. He described the pain as “muscle cramping,” explained that it has been worsening and currently rated it as a 10/10. Pt denied taking any medications to alleviate the pain. Pt states he never experienced this type of pain before. Pt also admitted that he has had some non-bloody diarrhea, which he did not remember the exact color of, and described as “liquidy,” after episodes of eating, but has overall not really had an appetite. Additionally, he stated that he feels SOB and lightheadedness when he tries to get up into a seated position. Of note, pt had a colonoscopy 10+ years ago which was “normal,” never had an upper endoscopy. Pt denied fever, chills, headache, nausea, vomiting, constipation, flank pain, dysuria, urinary frequency, dysphagia, eructation, or heartburn. He denies any recent injuries, trauma or stressful events, recent travel or sick contacts.

Past Medical History 

PMH – HTN, HLD, DM2

Immunizations – immunizations up to date. 

Screening Tests and Results – none.  

Past Surgical History 

None 

Denies past injuries or blood transfusions.  

Medications 

1. Glipizide-10 mg PO QD, for DM2
2. Metformin- 1000 mg PO BID, for DM2
3. Simvastatin-20 mg PO QD, for HLD
4. Lisinopril- 10 mg PO QD, for HTN
5. Hydrochlorothiazide- 12.5 mg PO QD, for HTN 

Allergies 

No known drug, food, or seasonal allergies.  

Family History 

Denies any known family history of gastric cancer or colorectal cancer

Social History 

Pt is a married male who lives in a house in Ozone Park, NY with his wife. Pt works as a salesman. He is currently sexually active with his wife only and denies any past hx of STI’s.

Habits- Pt drinks 1-2 cups of tea a day, admits to “social” ETOH use- about 2-3 drinks per week. Denies smoking, or illicit substance use. 

Travel – Denies any recent travel or sick contacts.  

Diet – Pt states he eats toast and butter for breakfast, and usually rice, vegetables, and chicken or meat for lunch and dinner. 

Exercise – Patient states he walks for about 30 minutes to an hour every day 

Sleep – Pt states he sleeps around 6-8 hours/night, has been sleeping well throughout the night.  

Review of Systems 

General – Admits to generalized fatigue. Denies, unintentional weight loss, fever, chills, or sweats.

Skin, Peripheral Vascular – Denies changes in skin texture/temperature, ulcerations, discolorations, rashes, erythema, or pruritus. Denies intermittent claudication, pallor, paresthesia, numbness/tingling, or edema.  

Head & Neck – Admits to lightheadedness when attempting to sit up. Denies any headaches, LOC, or head trauma. Wears prescription glasses for reading. Denies visual disturbances, photophobia, sore throat, neck stiffness/mass. 

Pulmonary – Admits to SOB when attempting to sit up. Denies cough, hemoptysis, wheezing, or hx of COPD/asthma. 

Cardiovascular – Admits to HTN and abdominal pain that radiates to his chest. Denies syncope, edema, history of arrhythmia, heart murmur, or CAD.   

GI – Admits to 3 days of upper quadrant abdominal pain, non-bloody diarrhea, and decreased appetite. Denies nausea, vomiting, hematemesis, constipation, dysphagia, eructation, rectal bleeding, blood in stool, or abnormal color/odors of stool.  

GU – Denies urinary frequency or urgency, oliguria, polyuria, dysuria, flank pain, or hx of BPH. 

MSK – Denies any muscle/joint pain or hx of arthritis. 

Hematological – Denies easy bruising or bleeding, lymph node enlargement, blood transfusions, or hx of DVT/PE or anemia.  

Endocrine – Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, excessive sweating, goiter, or hx of DM or thyroid disease. 

Psychiatric – Denies depression/sadness, anxiety, agitation, or ever seeing a mental health professional  

Neurological – Denies any changes in memory/cognition, weakness, abnormal or uncontrollable movement, unsteady gait, or LOC. 

PHYSICAL EXAM

General – Well-developed male, well-groomed with good hygiene, looks appropriately his stated age of 57, no difficulty ambulating. The patient is resting supine in ER bed, he is A/O x 3, in no acute distress. 

Vital Signs (1/13/22 @ 23:30) 

BP 129/79 (left arm, supine), 

HR 124 regular rhythm

Temp 37.5 C (oral)

SpO2 95% on RA

RR 18 unlabored

Height 66 in.            Weight 160 lbs                           BMI 25.8

Skin – Skin is warm and dry with no diaphoresis. Good turgor. No wounds, masses, ulcerations, discolorations, rashes, bruises, pruritus, or signs of infection. 

HEENT – Head is normocephalic, atraumatic, and nontender throughout. PERRLA, sclera white with no icterus, cornea and conjunctiva clear, full visual fields, EOMs intact. Mild strabismus noted. Mucous membranes are pink and moist, with no signs of cyanosis. No exudates, erythema or swelling of pharynx. Neck is supple with no masses, tenderness, thrills or bruits.  

Heart – Tachycardic, regular rhythm, carotid pulses are 2+ bilaterally with no bruits, no JVD. S1 and S2 distinct without any murmurs or abnormal heart sounds appreciated.  

Lungs – Lung sounds clear bilaterally, with no adventitious sounds. Respirations are normal and unlabored with no accessory muscle use.  

Abdomen – Abdomen is soft, non-distended, and tender to palpation to the right and left upper quadrants and epigastric region, guarding appreciated. + Murphy’s sign. No palpable masses, bowel sounds are present and normoactive throughout all 4 quadrants. Tympanic throughout with no rebound, no pulsatile masses, no CVA tenderness.  

Extremities – 2+ peripheral pulses. No edema, clubbing, cyanosis, or ulcerations. Full ROM

Psych – A/O x 3, no agitation.  

Neuro – No focal deficits, no gait abnormalities 

DIFFERENTIAL DIAGNOSIS 

1. Cholecystitis- Pt has upper quadrant pain, acute in onset, very severe, causes SOB (so painful with taking breaths), positive Murphy’s sign, has non-bloody diarrhea, worsened with eating, loss of appetite. However, pt denies nausea, vomiting, fever
2. Pancreatitis – Pt has severe upper quadrant (epigastric) abdominal pain that radiates to his chest, tachycardia, loss of appetite. However, no fever, nausea, or vomiting
3. Appendicitis- Pt has upper quadrant pain, loss of appetite, diarrhea. However, denies fever, nausea, vomiting.
4. Peptic Ulcer Disease-Pt has epigastric abdominal pain that is aggravated by eating. However, no heartburn, eructation, flatulence, came on suddenly and denies history of stressful events triggering. Pt states he never had anything like this before.
5. Diverticulitis- pt has abdominal pain, tenderness, diarrhea, and loss of appetite. However, it is upper quadrant and more common with diverticulitis is LLQ pain and constipation, no h/o diverticulitis

LABS (1/13/22 @ 20:49)

CBC – WBC’s 12.98 

76% neutrophils and 3% bands (no left shift) (16% lymphocytes). H&H within normal limits. 

CMP – Na 133, Cl 95, Glucose 368

LFTs – Total bili-2.3, Direct Bili-.5, Indirect Bili-1.8, Alanine Aminotransferase-43 (slightly high)

Coags – Pt-13.8, INR-1.20

VBG- pC02-34 (L), p02-44 (H), 02 sat venous-82, Na-131, Cl-95, Ca-1.04, Glucose-386, Lactate 3.40 

U/A – Urine glucose >1000, ketones-15, trace blood, RBC-6 protein-30

Troponin- negative

COVID – negative, 1/13/22 

IMAGING/TESTS  

Abdominal Ultrasound

Reason:Upper Quadrant abdominal pain

Findings: gallbladder is distended, wall does not appear significantly thickened, no pericholecystic fluid identified. No cholelithiasis identified. Majority of pancreas is obscured by bowel gas- visualized portions demonstrate increased echogenicity. CBD is not dilated- measures 3 mm in diameter

Impression: Distended gallbladder without sonographic evidence of cholelithiasis or acute cholecystitis

CT Angiography Chest with IV Contrast/ CT abdomen/pelvis with IV contrast

Reason: Chest Pain/ Abdominal Pain

Findings: No filling defect suspicious for PE, mild bibasilar atelectasis, no consolidation/ pneumothorax/ pleural effusion. Thoracic and abdominal aorta showed mild atherosclerotic plaque.

Gallbladder distended with marked wall thickening and pericholecystic edema. No intra- or extra-hepatic biliary ductal dilation, no hydronephrosis, no retroperitoneal or mesenteric adenopathy, no free intraperitoneal fluid or air.

Impression: Findings consistent with acute cholecystitis

DIAGNOSIS: Acute Cholecystitis/ Sepsis Due to Acute Cholecystitis→ HR>90, WBC>12,000, and evidence of acute infection

ASSESSMENT 

64 y/o male with PMH Htn, HLD, and DM2 who presented with severe upper quadrant abdominal pain x 3 days, found to have acute cholecystitis on CT scan. Upon arrival in ED pt was tachycardic, otherwise hemodynamically stable. Pt is to be admitted for emergent operative management of cholecystitis consisting of laparoscopic cholecystectomy, to be done early in the AM. 

PLAN 

1. Acute Cholecystitis
   1. Admit to Surgery A Green Team – Dr. Hagler, floor with telemetry bed, for acute cholecystitis, Plan for laparoscopic cholecystectomy this AM, first or second case
   2. Diet-NPO except meds- lisinopril 10 mg, simvastatin 20 mg @ 0900, hold hydrochlorothiazide and DM2 medications, insulin sliding scale
   3.  IV fluids-> Lactated ringers drip 50 mL/ hr
   4. IV antibiotics- Zosyn (Piperacillin Tazobactam)-4.5 g IV Q8hrs
   5. Repeat Labs in AM, pre-op labs-including COVID, coags, and T+S
   6. Pain control-acetaminophen 975 mg PO, Q6hrs , ibuprofen 400 mg, PO, Q6hrs morphine 4 mg IV PRN, ondansetron, 4 mg, IV, PRN
   7. Out of bed and in chair
   8. Strict I/O’s with foley
2. Hyperglycemia-insulin sliding scale
3. Atelectasis prophylaxis – Incentive spirometer 
4. DVT prophylaxis – Enoxaparin 40mg SQ QD (@0900)
5. Hypertension-well-controlled, continue home medications, hold HCTZ
6. Hyperlipidemia- well-controlled, continue home medications
7. Referral for screening colonoscopy