allergies: penicillins attending: chief complaint: nausea, vomiting, abdominal pain major surgical or invasive procedure: ercp and sphincterotomy percutaneous biliary drain s/p removal history of present illness: mrs. is a yo f with a history of copd, depression, tia, gerd, left cea, htn, macular degeneration, who was referred to ed for further management of abdominal pain and elevated liver enzymes. she was in her usual state of health yesterday before developing sudden onset of severe right upper quadrant pain at 7pm, which was constant, nonradiating, and accompanied by multiple episodes of vomiting over the course of the night. she was diaphoretic and reported a pressure sensation extending essentially from neck to her lower abdomen. she denies previous similar episodes, and has no history of biliary disease though two daughters are s/p cholecystectomy. she subsequently presented to osh ed this morning, where a ct abdomen revealed a thickened gallbladder wall without evidence of stones. she was given ciprofloxacin and flagyl, and was transferred to ed for further management. in the ed, her initial vitals were 99.6 84 124/69 16 96%/2l. she was intermittently tachycardic to >100, and a note was made of a transiently low bp to 80s systolic, however subsequent pressures were normal. her abdominal exam revealed some guarding. her ruq u/s revealed gallbladder wall thickening with gallstones, but no evidence of cbd dilation. her transaminases and ap were strikingly elevated. her troponin was elevated to 0.2, trending up to 0.55 prior to transfer with a ckmb elevation to 15. she received aspirin at the osh this morning. while her ekg was not available on arrival to floor, note was made of st depressions laterally. surgery was consulted and recommended perc-bili drain due to poor surgical candidacy. ercp also notified of case. on the icu floor, her vs were hr77, bp135/110, rr21, sat 100%3lnc. she was comfortable and denies any further abdominal pain. she is hungry. no current chest pain. on review of systems, she denies shortness of breath, cough, sore throat, current nausea or vomiting, jaundice, current fevers or chills, rigors, hematuria, diarrhea, melena, hematochezia. past medical history: -copd -tia (x2) -gerd -schatzki ring s/p dilation with persisting dysphagia -macular degeneration -carotid stenosis s/p cea -hypertension -previous tobacco use -hypercholesterolemia -early alzheimers -urge incontinence social history: patient lives alone in , requiring increasing help from daughters to accomplish adls/iadls. previous 20py history of smoking, quit 30 years ago. no alcohol. recently lost her husband a few months ago. family history: mulitple siblings with mi/cad sister cva, daughter epilepsy physical exam: vitals: temp 97.7 hr77, bp135/110, rr21, sat 100%3lnc general: alert, oriented x2, no acute distress heent: sclera anicteric, mmm, oropharynx clear neck: supple, jvp not elevated, no lad lungs: quiet breath sounds but otherwise clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: mild tenderness to palpation in the right upper quadrant but no sign. no diffuse abdominal pain, guarding, or rebound tenderness. no hepatosplenomegaly. +bs. gu: foley in place ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema neuro: cn ii-xii intact, strength 5/5 throuhgout, no sensory deficits pertinent results: 1. labs on admission: 06:45am blood wbc-11.5*# rbc-4.05* hgb-10.3* hct-32.6* mcv-81* mch-25.4* mchc-31.5 rdw-15.3 plt ct-100* 06:45am blood neuts-81* bands-3 lymphs-4* monos-12* eos-0 baso-0 atyps-0 metas-0 myelos-0 03:12pm blood pt-16.5* ptt-31.8 inr(pt)-1.5* 06:45am blood glucose-230* urean-18 creat-1.6* na-134 k-2.9* cl-99 hco3-24 angap-14 06:45am blood alt-377* ast-723* ld(ldh)-714* ck(cpk)-151 alkphos-262* totbili-2.0* dirbili-1.6* indbili-0.4 06:45am blood lipase-27 06:45am blood ck-mb-15* mb indx-9.9* 06:45am blood ctropnt-0.20* 12:15pm blood ctropnt-0.55* 08:43pm blood ck-mb-32* mb indx-7.9* ctropnt-0.99* 06:45am blood albumin-4.0 calcium-8.0* phos-1.0*# mg-1.6 07:04am blood lactate-2.1* . 2. labs on discharge: 3. imaging/diagnostics: - liver/gallbladder u/s: 1. gallbladder wall edema and cholelithiasis; non-specific findings, cannot exclude acute cholecystitis; if clinical concern, hida can be considered. 2. no intra- or extra-hepatic biliary duct dilatation. 3. main portal vein patent. cxr:impression: 1. no pneumonia. mild bibasilar atelectasis. 2. mild pulmonary edema and small bilateral pleural effusions. ue us: impression: no evidence of deep vein thrombus in the left upper extremity. brief hospital course: yo f with a history of depression, copd c/b pulmonary htn not on home o2, htn, hld, gerd, h/o tia, who presented with clinical and radiographic evidence of cholecystitis/cholangitis. her course has been notable for/complicated by icu admission, sepsis related nstemi, volume overload, paf, and poor oral intake. hospital course by issue: # cholecystitis/cholangitis: patient presented with ruq pain, nausea, and vomiting with radiographic evidence of gallbladder wall thickening and gallstones. she also had dramatic elevations in alk phosphatase, direct bilirubin, and transaminitis. surgery declined cholecystectomy based on high surgical risk, thus a percetaneous cholecystostomy tube was placed for decompression. patient was started on ciprofloxacin, metronidazole, and vancomycin for emperic coverage (given pcn allergy) for plan of a total 14 day course. bile fluid culture revealed clostridium perfringens. percutaneous tube was self discontinued accidentally and attempt was made to replace but there was no longer biliary dilatation. ercp was performed with sphincterotomy and patient remained clinically stable on antibiotics. she completed >2 weeks of triple antibiotics prior to discharge. she had a slight rise in her alkaline phosphatase during admission but this decreased on discharge. she was discharged pain free. # nstemi: patient had elevated troponin which trended up from 0.20 -> 0.97 and mb 15 -> 32 - >23. patient has multiple risk factors. mb peaked at 32. it was unclear whether this was a demand event vs. an acute plaque rupture coronary syndrome. echo showed mild focal hypertrophy of the basal septum with mild regional lv systolic dysfunction. initially patient received heparin but was later stopped in anticipation for ercp. patient was started on medical therapy for cad with aspirin, beta blocker, low dose acei, and high dose statin. asa was held for ercp and should be restarted . # copd: echo showed evidence of pulmonary hypertension and rv dilation with systolic dysfunction as well as severe tr likely copd. she was started on spiriva as she was not on any medical therapy for her copd prior to admission. however, it is unclear whether pulmonary htn is due solely to copd as patient has not been hypoxic. . #chf, acute on chronic, r>l sided sxs, preserved lvef w diastolic dysfunction: she has diastolic dysfcuntion based on tte. her volume was managed with prn lasix based on symptoms of dyspnea and orthopnea. # depression: this seems to have worsened over the course of her hospitalization. fluoxetine was continued. # paroxysmal atrial fibrillation: given rhythm abnormality and history of tia patient was started on aspirin and warfarn after discussion with family based on high chads2 score. these were then held around the time of ercp. her rates have been well controlled on bb and she has been intermittently in sinus rhythm. she is at significant risk of stroke due to the a.fib, and was started on pradaxa for stroke prophylaxis. please monitor for bleeding. #delirium: patient had mild delirium not requiring medical intervention during hospital course thought to be related to her infection that resolved at the time of discharge. this resolved. please note she is very hard of hearing and has poor vision so communication is challenging. #anemia: pt presented with hct 30s that went as low as 22's. she refused blood transfusion during admission. i reviewed this with her again on the day of discharge, when her hct was 22.1, and she once again refuses blood transfusion, stating she "feels fine" without it. #code/goals of care: pt was dnr/dni except for procedures. regarding nutrition she was not taking adequate nutrition during end of hospitalization felt to be due to depression. discussed options for peg tube and patient (corroborated by daughters) said that she did not want to have an invasive nutritional support. they were counseled that poor nutrition could lead to dehydration. they are pondering possible "do not hospitalize" status upon discharge. medications on admission: albuterol sulfate - 90 mcg hfa aerosol inhaler - 2 puffs four times a day as needed for wheeze fluoxetine - 20 mg tablet - 1 tablet(s) by mouth once a day oxybutynin chloride - 5 mg tablet - 1 tablet(s) by mouth twice a day aspirin - (prescribed by other provider) - 325 mg tablet - 1 discharge medications: 1. trazodone 50 mg tablet sig: 0.5 tablet po hs (at bedtime) as needed for insomnia. 2. albuterol sulfate 2.5 mg /3 ml (0.083 %) solution for nebulization sig: one (1) inhalation q4h (every 4 hours) as needed for shortness of breath. 3. ipratropium bromide 0.02 % solution sig: one (1) inhalation q6h (every 6 hours) as needed for shortness of breath or wheezing. 4. fluoxetine 20 mg capsule sig: one (1) capsule po daily (daily). 5. atorvastatin 80 mg tablet sig: one (1) tablet po daily (daily). 6. multiple vitamins daily tablet sig: one (1) ml po once (once) for 1 doses. 7. calcium carbonate 500 mg calcium (1,250 mg) tablet sig: one (1) tablet po three times a day. 8. metoprolol tartrate 25 mg tablet sig: one (1) tablet po q8h (every 8 hours). 9. tiotropium bromide 18 mcg capsule, w/inhalation device sig: one (1) cap inhalation daily (daily) as needed for copd. 10. lisinopril 5 mg tablet sig: one (1) tablet po daily (daily). 11. aspirin 81 mg tablet, chewable sig: one (1) tablet, chewable po daily (daily). 12. dabigatran etexilate 150 mg capsule sig: one (1) capsule po bid (2 times a day). discharge disposition: extended care facility: nursing home - discharge diagnosis: cholangitis and sepsis from biliary obstruction, most likely from a stone - now s/p percutaneous drainage then ercp sepsis induced nstemi discharge condition: mental status: confused - sometimes. level of consciousness: alert and interactive. activity status: out of bed with assistance to chair or wheelchair. discharge instructions: you were admitted for cholangitis (infection of your galbladder and biliary tract) and required admission to the icu. you were given antibiotics and improved. you also had an ercp with sphincterotomy. followup instructions: you should follow up with your primary care doctor in the next 2-4 weeks. Procedure: Venous catheterization, not elsewhere classified Endoscopic sphincterotomy and papillotomy Percutaneous aspiration of gallbladder Diagnoses: Subendocardial infarction, initial episode of care Coronary atherosclerosis of native coronary artery Esophageal reflux Pure hypercholesterolemia Congestive heart failure, unspecified Acute kidney failure, unspecified Unspecified septicemia Chronic airway obstruction, not elsewhere classified Chronic kidney disease, Stage IV (severe) Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified Atrial fibrillation Acute on chronic diastolic heart failure Personal history of tobacco use Depressive disorder, not elsewhere classified Sepsis Hypopotassemia Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits Do not resuscitate status Metabolic encephalopathy Alzheimer's disease Dementia in conditions classified elsewhere without behavioral disturbance Dehydration Cholangitis Other and unspecified coagulation defects Disorders of magnesium metabolism Urinary incontinence, unspecified Chronic pulmonary heart disease, unspecified Tricuspid valve disorders, specified as nonrheumatic Anorexia Other dependence on machines, supplemental oxygen Calculus of gallbladder with acute cholecystitis, with obstruction Dysphagia, unspecified Malnutrition of mild degree Personal history of allergy to penicillin