allergies: patient recorded as having no known allergies to drugs attending: chief complaint: abdominal pain major surgical or invasive procedure: ercp with placement of history of present illness: ms. is a 78 yo female who developed right upper quandrant pain and vomiting a few days ago. she denied hematemasis. she went to where she was noted to be jaundiced. although patient had not noticed this, she states her urine became tea colored a few weeks ago. she was found to have at common bile duct stone by ultrasound at and was trasnferred here for ercp. at , she was given zofran, dilaudid 0.5 iv, ativan 0.5 mg iv, and 500 cc of ns. she denies fevers, chills, lightheadedness, nausea, vomiting. . in the ed, vitals were t 97.7, hr 71, bp 133/77, rr 16, 97% on ra. at present, surgery and ercp were consulted with a plan to undergo ercp at some point. she got a dose of unasyn in the ed. . on the , she denies abdominal pain. she has persistent nausea and vomiting. further history is limited by somnolence secondary to sedating meds received in the ed. . review of sytems: unable to obtain due to sedation secondary to sedating meds past medical history: gerd depression anxiety s/p hysterectomy social history: patient recently suffered the loss of a friend to cancer. she denies tobacco or alcohol use. patient is independent and lives alone. family history: patient denies family history of hepatic, pancreatic, or biliary conditions physical exam: vitals: t: 98.4, hr 71, bp 144/61, rr 14, 96% on ra general: somnolent but arousable, jaundiced heent: sclera icteric, mmm, oropharynx clear neck: supple lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi cv: regular rate and rhythm, normal s1 + s2, no murmurs, rubs, gallops abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly gu: no foley ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema pertinent results: .. \ 12.4 / 10.0 ---- 266 .. / 36.8 \ . diff: 88.4%n, 7.3%l, 3.7%m, 0.2%e, 0.4%b . 141 | 101 | 14 / --------------- 175 3.9 | 30 | 0.6 \ . alt 197 ast 112 ap 432 t. bili - 9.0 alb 3.8 lipase 40 . . pt 11.1 ptt 21.2 inr 0.9 . osh lfts: t. bili 3.6 alt 228 ast 128 alk phos 492 wbc 10 . micro: blood cultures x 1 - ngt . . images: osh sono - s with intrahepatic and extrahepatic biliary dilitation. gallbladder sludge and right renal cyst. common bile duct is dilated to 1.2 cm. . ercp ercp performed under mac: two large stones and copious amount of stone fragments and debris were extracted, biliary was placed. abrupt termination of the duct at the ampulla was noted, thought to represent edema vs. ampullary neoplasm. plan to repeat ercp in 4 weeks for removal and biopsies of the ampulla. 06:20am blood wbc-10.0 rbc-3.97* hgb-12.4 hct-36.8 mcv-93 mch-31.3 mchc-33.8 rdw-13.3 plt ct-266 05:22am blood wbc-4.8# rbc-3.95* hgb-12.2 hct-37.2 mcv-94 mch-30.9 mchc-32.9 rdw-13.0 plt ct-226 07:02am blood pt-11.1 ptt-21.2* inr(pt)-0.9 06:20am blood glucose-175* urean-14 creat-0.6 na-141 k-3.9 cl-101 hco3-30 angap-14 05:22am blood glucose-102* urean-10 creat-0.6 na-143 k-3.6 cl-106 hco3-30 angap-11 06:20am blood alt-197* ast-112* alkphos-432* totbili-9.0* 05:22am blood alt-174* ast-112* ld(ldh)-194 alkphos-413* totbili-9.0* 06:20am blood lipase-40 05:22am blood albumin-3.6 calcium-8.8 phos-2.6* mg-2.1 brief hospital course: ms. is a 78 yo female who developed right upper quadrant pain and vomiting a few days prior to presenting to the ed. she was admitted on for ercp for choledocholithiasis after an osh ultrasound showed intra and extra duct dilatation. she was given a dose of unasyn in the ed and again prior to ercp. an ercp was performed under mac on : two large stones and copious amounts of stone fragments and debris were extracted, and biliary was placed. abrupt termination of the duct at the ampulla was noted, thought to represent edema but concern was raised for possible ampullary neoplasm. the plan by the ercp team is to repeat ercp in 4 weeks for removal and biopsies of the ampulla. she did well post-ercp without symptoms of abdominal pain, no nausea or vomiting. general surgery was consulted regarding need for cholecystectomy. general surgery will contact patient to schedule cholecystectomy after repeat ercp. she was discharged from the icu to home after tolerating a regular diet. upon discharge, her lfts and total bilirubin were still elevated but stable, and she remained icteric. she had no complaints of nausea, vomiting or abdominal pain and had no fevers. she was instructed to follow up with her primary care physician the day after discharge for followup labs which should be faxed to the gi team at . her code status was confirmed as full code this admission. medications on admission: effexor 75 mg daily omeprazole 20 mg daily discharge medications: 1. outpatient lab work please draw ast, alt, alk phos, tbili in days and fax results to dr. , gi department, 2. venlafaxine 75 mg capsule, sust. release 24 hr sig: one (1) capsule, sust. release 24 hr po daily (daily). 3. omeprazole 20 mg tablet, delayed release (e.c.) sig: one (1) tablet, delayed release (e.c.) po once a day. 4. compazine 5 mg tablet sig: 1-2 tablets po every 6-8 hours as needed for nausea for 4 days. disp:*5 tablet(s)* refills:*0* discharge disposition: home discharge diagnosis: primary diagnosis: cholelithiasis secondary diagnosis: gastroesophageal reflux disease discharge condition: stable, tolerating regular diet, stable hemodynamics, afebrile. discharge instructions: dear ms. , you were admitted to the hospital with gallstones. you underwent a procedure called ercp to remove the gallstones. they saw inflammation of the junction between the bile ducts and the bowel, so the gi doctors placed a that is keeping your ducts in your gallbladder open. you will need this removed in 4 weeks. . if you have fever, chills, rigors, nausea, vomiting, abdominal pain, changes in the color of your urine (dark-), stools or anything else that concerns you please call your primary care physician right away. . your medications were left unchanged. followup instructions: please follow up with your primary care provider, . , next week. he should draw labs to test your liver (ast/alt/tbili/aphos) and fax them to dr. in the gi department here at . dr. fax number is: . Procedure: Endoscopic removal of stone(s) from biliary tract Endoscopic sphincterotomy and papillotomy Endoscopic insertion of stent (tube) into bile duct Diagnoses: Esophageal reflux Dysthymic disorder Calculus of bile duct without mention of cholecystitis, with obstruction