History of Present Illness:

21 y/o F, with no significant PMHx, who presents to the ED c/o intermittent epigastric pain x 1 month. The patient was seen at another hospital for similar pain yesterday and was diagnosed with cystitis, currently on Keflex, and transaminitis. She states she came to the ED today because the pain is not improving. The patient states the pain is burning, sharp and is worsened when eating spicy foods or soda and starts one hour after eating such foods. She states she has taken Tylenol for the pain with no relief. She also reports the pain radiates to her back. Patient reports SOB associated with the pain but denies fever, chills, chest pain, nausea, vomiting, change in bowel habits, dysuria, hematuria or any other symptoms at this time.

PMHx: cystitis, transaminitis

Medications: Keflex 500 mg 1 capsule PO every 6 hours for 7 days

Allergies: NKDA

PSHx: denies

PFHx: denies

Social history: Denies tobacco, illicit drug or alcohol use

Review of Systems:

General: Denies recent weight loss or gain, loss of appetite, generalized weakness, fatigue, fever, chills, night sweats

Skin: denies changes to skin color, pruritus

Pulm: Denies SOB, cough, sputum production, hemoptysis

CV: Denies chest pain, palpitations, irregular heartbeat, edema, syncope, heart murmur

GI: Admits to epigastric abdominal pain, intolerance to specific foods. Denies nausea, vomiting, pyrosis, flatulence, eructations, diarrhea, constipation, change to bowel habits, rectal bleeding, hematochezia.

GU: Denies frequency, nocturia, urgency, oliguria, polyuria, dysuria, hematuria

Nervous System: Denies seizures, headache, loss of consciousness, sensory disturbances, weakness

Physical Exam:

Vitals: T 98.2, HR 81 bpm, BP 114/75, RR 18 breaths/minute, O2 sat 97%, Wt 185 lb, Ht 5’6”

Gen: Alert and oriented, in no acute distress. Well-groomed and appropriately dressed.

Skin: no jaundice

HEENT: normocephalic, atraumatic, mucous membranes moist, no erythema in pharynx, no scleral icterus

CV: Regular rate and rhythm

Pulm: Clear to auscultation bilaterally

Abd: Obese with striae present, normoactive bowel sounds, RUQ and epigastric tenderness to palpation, negative Murphy’s sign

Neuro: no focal deficit

Psych: normal mood and behavior

 Assessment:

21 y/o F, with no significant PMHx, who presents to the ED c/o intermittent epigastric pain x 1 month with RUQ and epigastric tenderness on palpation.

Differentials:

Choledocholithiasis, Cholecystitis, Cholelithiasis, peptic ulcer disease, GERD, hepatitis

Plan:

CBC

BMP

LFTS – recheck to see if levels elevated as they were yesterday

Urine pregnancy

Lipase

Hepatitis B surface antigen, Hepatitis B core antibody

Hepatitis C antibody

Hepatitis A antibody 

PT, PTT, type and screen

Administer Famotidine 20 mg in sodium chloride 100mL IV

RUQ US

Addendum:

Labs unremarkable except direct bilirubin 0.4 mg/dL, Alk phos 202 U/L, ALT 360 U/L, AST 437 U/L

RUQ US showed mobile cholelithiasis and gallbladder wall thickening, consistent with acute cholecystitis; dilated common hepatic/proximal CBD may be due to Mirizzi’s syndrome versus choledocholithiasis. Hepatosplenomegaly; fatty infiltration/hepatocellular disease

GI consulted and MRCP was ordered, which showed cholelithiasis with no choledocholithiasis.

Disposition:

Patient admitted under surgery service for laparoscopic cholecystectomy scheduled for tomorrow.

Education:

You have cholelithiasis, which are stones in your gallbladder, an abdominal organ that releases bile to help digest food. This is why you have been having upper abdominal pain that is worsened with certain foods. Tomorrow you will have your gallbladder removed laparoscopically, which means small incisions will be made in about four places in your abdomen in order to take out your gallbladder with the aid of a camera.