
Name:  ___                     Unit No:   ___

Admission Date:  ___              Discharge Date:   ___

Date of Birth:  ___               Sex:   M

Service: MEDICINE

Allergies:
Sulfa (rash)
Codeine (nausea)

Attending: ___.

Chief Complaint:
Fever, abdominal pain, yellow eyes

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and stone extraction
Esophagogastroduodenoscopy with cauterization

History of Present Illness:
___ is a ___ year-old gentleman with a history notable for prior
cholecystectomy (___) who presented to the ED with 2 days of
worsening right upper quadrant abdominal pain, fevers up to
102.8F at home, and his wife noticed his eyes and skin turning
yellow. He reports the pain started gradually, initially dull
and diffuse, then localizing to the right upper quadrant with
radiation to his right shoulder. Associated with rigors, nausea,
and two episodes of non-bloody emesis. He denies diarrhea. He
reports his urine has been dark "like tea" for the past day and
his stool has been lighter than usual. He denies any prior
episodes like this since his cholecystectomy. He has not
traveled recently and denies any new medications or supplements.

In the ED, vitals were T 103.1, HR 112, BP 88/54, RR 22, SpO2
96% on RA. He appeared jaundiced and was tender in the RUQ with
a positive ___ sign. Labs were notable for WBC 18.4 with 89%
neutrophils, total bilirubin 8.2 (direct 6.9), alkaline
phosphatase 482, AST 312, ALT 278, lipase 42 (normal). Lactate
was 3.1. INR was 1.8 (he takes warfarin at home for history of
prior DVT). Creatinine was 4.2, up from his baseline of 3.1 per
recent outpatient records from ___. His fingerstick glucose was
342.

RUQ ultrasound showed dilated common bile duct measuring 12mm
(previously 6mm on imaging from ___) with possible shadowing
in the distal CBD, no intrahepatic ductal dilatation. CT abdomen
and pelvis with contrast showed dilated CBD with a 9mm stone
impacted at the ampulla, mild periductal enhancement, no
evidence of cholangiocarcinoma or mass lesion, no free air.

He was started on piperacillin-tazobactam and normal saline
boluses in the ED. His blood pressure improved to 102/64 after
2L of NS. Blood cultures were drawn x2 peripherally. GI was
consulted for urgent ERCP.

Past Medical History:
- Cholecystectomy (laparoscopic, ___)
- Chronic kidney disease (followed by Dr. ___ at ___, last Cr
  3.1, no dialysis)
- Coronary artery disease, s/p 3-vessel CABG (___)
- Systolic heart failure, last echo ___ showed EF 35%, moderate
  MR, mild TR, mild pulmonary HTN (RVSP 42)
- Atrial flutter, on metoprolol for rate control
- Deep vein thrombosis (___, left lower extremity), on warfarin
- Type 2 diabetes, on insulin and metformin per Dr. ___
- Peripheral neuropathy, bilateral lower extremities
- Recurrent episodes of gouty arthritis per rheumatology
- BPH
- Remote history of alcohol use, sober x 15 years

Social History:
___
Lives with wife. Retired electrician. Former smoker, 30
pack-years, quit ___. Former heavy drinker, sober x 15 years,
attends ___. No illicit drug use. Independent with ADLs at
baseline though wife reports he has been more fatigued and short
of breath on exertion recently, can walk about half a block
before needing to rest.

Family History:
Father died of "liver cancer" at age 72. Mother with type 2
diabetes and stroke. Brother with colon cancer at age 65,
currently in remission.

Physical Exam on Admission:
VS: T 102.6, HR 108, BP 94/58, RR 20, SpO2 97% on RA
Wt 104.2 kg, Ht 174 cm
GENERAL: Ill-appearing, jaundiced male in moderate distress
HEENT: Icteric sclerae, dry mucous membranes, no
lymphadenopathy
NECK: Supple, JVP elevated to approximately 10cm above RA
CARDIAC: Irregularly irregular rhythm, tachycardic, 2/6 systolic
murmur best at apex, no gallop
LUNGS: Diminished at bases bilaterally, no wheezes, scattered
crackles in the right base
ABDOMEN: Soft, significant tenderness in the RUQ, no
peritoneal signs, no palpable masses, well-healed
laparoscopic cholecystectomy scars x4, normoactive bowel
sounds. Liver edge palpable 2cm below costal margin.
EXTREMITIES: 2+ pitting edema bilateral lower extremities to
mid-shin, left greater than right. Diminished sensation to
light touch in stocking distribution bilaterally. Tophaceous
deposits noted on bilateral first MTP joints and left olecranon.
SKIN: Jaundiced. Multiple ecchymoses on forearms. No rashes.

Physical Exam on Discharge:
VS: T 98.4, HR 76, BP 128/72, RR 16, SpO2 96% on RA
GENERAL: Alert, comfortable, jaundice resolving
CARDIAC: Irregularly irregular, normal rate, systolic murmur
unchanged
LUNGS: Clear to auscultation bilaterally, no crackles
ABDOMEN: Soft, non-tender, non-distended
EXTREMITIES: 1+ edema bilateral LE, improved from admission.
Tophaceous deposits unchanged.

Pertinent Results:
ADMISSION LABS:
WBC 18.4, Hgb 8.9 (baseline per PCP records ~9.2), Hct 27.1,
Plt 198
Na 138, K 3.1, Cl 100, HCO3 20, BUN 68, Cr 4.2 (baseline 3.1),
Glucose 342
Ca 8.1, Mg 1.6, Phos 5.8
AST 312, ALT 278, ALP 482, T.Bili 8.2, D.Bili 6.9, Albumin 2.8
Lipase 42
Troponin <0.01 x3 (negative)
Procalcitonin 4.2
INR 1.8, PT 21.4
Lactate 3.1 -> 1.4 after fluids
UA unremarkable
HbA1c 9.8% (ordered by medicine team during admission)

INTERVAL LABS:
Day 2 (post-ERCP):
- Lipase 1840 (from 42)
- Amylase 1122
- WBC 12.4 (down from 18.4)
- T.Bili 5.4 (improving)
- Cr 4.0 (slight improvement)
- K 3.4 (after repletion)

Day 4:
- Lipase 680 (trending down)
- WBC 8.2
- T.Bili 3.1
- Cr 3.5
- Hgb 7.2 (drop from 8.9)
- Guaiac positive stool

Day 5 (post-EGD):
- Hgb 8.1 (after 2u pRBC transfusion)
- Cr 3.3
- T.Bili 2.4
- K 3.8

DISCHARGE LABS:
WBC 6.8, Hgb 8.8, Hct 26.8, Plt 224
Na 140, K 4.0, Cl 102, HCO3 22, BUN 52, Cr 3.3, Glucose 198
AST 48, ALT 62, ALP 188, T.Bili 1.8, Albumin 2.6
INR 2.1

MICROBIOLOGY:
Blood cultures (x2, admission): No growth at 5 days
Urine culture: No growth

IMAGING:
RUQ Ultrasound (admission): Common bile duct dilated to 12mm.
Possible shadowing in the distal CBD suggestive of
choledocholithiasis. No intrahepatic ductal dilatation. Status
post cholecystectomy. No ascites.

CT Abdomen/Pelvis with contrast (admission): 9mm stone impacted
at the ampulla of Vater with upstream biliary dilatation. Mild
periductal enhancement consistent with cholangitis. No evidence
of mass lesion or cholangiocarcinoma. Bilateral small pleural
effusions, right greater than left. Mild hepatomegaly.
Atherosclerotic calcification of the aorta and iliac arteries.
Both kidneys show cortical thinning consistent with chronic
kidney disease. Scattered diverticula in the sigmoid colon
without diverticulitis.

ERCP (Day 1): Cannulation of the major papilla was performed.
Cholangiogram demonstrated a 9mm stone in the distal common bile
duct with upstream dilatation to 12mm. Biliary sphincterotomy was
performed. The stone was extracted using a balloon sweep. Occlusion
cholangiogram showed clear duct without residual filling defects.
Moderate amount of purulent bile was aspirated and sent for
culture (result: no growth). Small amount of oozing at
sphincterotomy site, hemostasis achieved with epinephrine
injection. Fluoroscopy was used for guidance throughout the
procedure. Estimated blood loss minimal.

EGD (Day 4): Performed for evaluation of melena and hemoglobin
drop. A ___ visible vessel was identified at the
sphincterotomy site with adherent clot. Hemostasis was achieved
with bipolar cauterization. No other source of bleeding
identified. No varices. Mild erythema in the gastric antrum,
biopsied (result: chronic gastritis, H. pylori negative). Small
hiatal hernia noted.

CXR (Day 5): Bilateral small pleural effusions, improved from
prior. No consolidation. Sternotomy wires intact. Median
sternotomy changes consistent with prior CABG.

Brief Hospital Course:
# Acute cholangitis secondary to choledocholithiasis
Patient presented with the classic triad of fever, jaundice, and
RUQ pain in the setting of CBD stone. He was hemodynamically
unstable on arrival requiring aggressive fluid resuscitation.
Blood cultures were drawn and broad-spectrum antibiotics
initiated. He met criteria for acute severe cholangitis given
hemodynamic compromise. ERCP was performed on hospital day 1
with successful sphincterotomy and stone extraction. Purulent
bile was aspirated. His fevers resolved within 24 hours of the
procedure and his bilirubin steadily trended down. Antibiotics
were narrowed to ciprofloxacin and metronidazole after cultures
remained negative and his clinical picture improved. He was
transitioned to oral antibiotics on day 5 to complete a 14-day
course.

# Post-ERCP pancreatitis
On hospital day 2, the patient developed worsening epigastric
pain radiating to the back with associated nausea. Lipase was
found to be elevated to 1840 (from 42 on admission). This was
consistent with post-ERCP pancreatitis, a known complication.
He was made NPO and managed with IV fluids and pain control with
IV acetaminophen and hydromorphone (avoiding NSAIDs given his
renal function). His symptoms gradually improved and he was
advanced to a low-fat diet by day 4. Lipase trended down to 680
and continued to improve.

# Upper gastrointestinal hemorrhage
On day 4, nursing noted melanotic stool and his hemoglobin was
found to have dropped from 8.9 to 7.2. Guaiac was positive.
Given recent ERCP with sphincterotomy, concern was for bleeding
from the sphincterotomy site. His warfarin had been held on
admission and INR was 1.3 at the time of the bleed. He was
transfused 2 units of packed red blood cells and an urgent EGD
was performed which identified a visible vessel at the
sphincterotomy site with adherent clot. Hemostasis was achieved
with bipolar cauterization. His hemoglobin stabilized at 8.8
post-transfusion and there were no further episodes of bleeding.
He was observed for an additional 48 hours with stable counts.
Incidental finding of chronic gastritis, biopsied, H. pylori
negative.

# Acute kidney injury on chronic kidney disease
Patient's creatinine on admission was 4.2, up from his baseline
of 3.1, likely pre-renal in the setting of acute infection and
dehydration. He was given careful IV fluid resuscitation given
his known heart failure. His creatinine gradually improved to 3.3
by discharge. Nephrotoxic medications were held. Nephrology was
informally consulted and agreed with management. His home
metformin was held given his AKI and the contrast exposure from
CT and ERCP, to be restarted as outpatient after reassessment of
renal function.

# Hyperglycemia / Diabetes management
His blood sugars ran in the 200-400 range throughout the
admission, likely in the setting of infection, steroids were not
given, and NPO status complicated management. His HbA1c returned
at 9.8%, indicating poorly controlled diabetes at baseline. Home
metformin was held given AKI. He was managed on sliding scale
insulin plus basal insulin (glargine) with endocrine pharmacy
input. His home dose of glargine was uptitrated from 22 units to
28 units nightly. Notably, he reported burning and tingling in
both feet "for years," consistent with his known diabetic
peripheral neuropathy. Gabapentin was continued at home dose
though held briefly when he was somnolent on day 3.

# Systolic heart failure
His JVP was elevated on admission and he had bilateral lower
extremity edema, consistent with his known HFrEF. Careful fluid
management was required balancing his pre-renal AKI with his
volume-overloaded state. Gentle diuresis with IV furosemide 20mg
x3 was given after his creatinine stabilized, with good response.
His home carvedilol was continued. Home lisinopril was held in the
setting of AKI and restarted at a lower dose on day 6.

# Atrial flutter
He was noted to be in atrial flutter with variable block
throughout the admission with rates generally 70s-90s. Home
metoprolol was continued. His anticoagulation with warfarin was
held given the GI bleed. At discharge, he was restarted on
warfarin with INR goal 2-3, with plan for close follow-up with
his PCP for INR monitoring.

# Hypokalemia
Potassium was 3.1 on admission, likely related to poor oral
intake and emesis. He received IV and oral potassium repletion
over the first 3 days and his potassium normalized to 4.0 by
discharge. This was monitored closely given his cardiac history.

# Anemia
His hemoglobin on admission was 8.9, close to his baseline of
~9.2 per PCP records. This dropped to 7.2 in the setting of the
GI bleed and he was transfused 2 units pRBC. He responded
appropriately with Hgb stabilizing at 8.8. His anemia workup
from his outpatient records showed it to be consistent with
anemia of chronic kidney disease. He is on epoetin alfa as an
outpatient, which was continued.

# DVT history / Anticoagulation
Home warfarin was held on admission given elevated INR and
upcoming procedures. He was not bridged with heparin given the
bleeding risk. Warfarin was restarted on day 7 after hemostasis
was confirmed. INR at discharge was 2.1. SCDs were used for VTE
prophylaxis while warfarin was held.

# Code status: Full code, discussed and confirmed with patient
and wife

Medications on Admission:
1. Warfarin 5mg daily
2. Carvedilol 12.5mg BID
3. Lisinopril 10mg daily
4. Amlodipine 5mg daily
5. Furosemide 40mg daily
6. Insulin glargine 22 units at bedtime
7. Metformin 500mg BID
8. Gabapentin 300mg TID
9. Allopurinol 100mg daily
10. Atorvastatin 40mg at bedtime
11. Pantoprazole 40mg daily
12. Tamsulosin 0.4mg at bedtime
13. Aspirin 81mg daily
14. Epoetin alfa 10,000 units SC weekly
15. Ferrous sulfate 325mg daily
16. Senna 8.6mg PRN

Discharge Medications:
1. Ciprofloxacin 500mg PO BID (to complete 14-day course, ___)
2. Metronidazole 500mg PO TID (to complete 14-day course, ___)
3. Warfarin 5mg daily (restarted, INR check in 3 days)
4. Carvedilol 12.5mg BID
5. Lisinopril 5mg daily (decreased dose)
6. Amlodipine 5mg daily
7. Furosemide 40mg daily
8. Insulin glargine 28 units at bedtime (INCREASED)
9. Metformin -- HELD until cleared by PCP
10. Gabapentin 300mg TID
11. Allopurinol 100mg daily
12. Atorvastatin 40mg at bedtime
13. Pantoprazole 40mg BID (INCREASED to BID given GI bleed)
14. Tamsulosin 0.4mg at bedtime
15. Aspirin 81mg daily (held, restart per PCP in 2 weeks)
16. Epoetin alfa 10,000 units SC weekly
17. Ferrous sulfate 325mg daily
18. Acetaminophen 650mg PO Q6H PRN pain

Discharge Disposition:
Home with services (visiting nurse for INR checks, wound checks)

Discharge Diagnosis:
Primary:
- Acute cholangitis due to choledocholithiasis
- Post-ERCP pancreatitis
- Upper gastrointestinal hemorrhage from sphincterotomy site

Secondary:
- Acute kidney injury
- Hyperglycemia

Discharge Condition:
Mental Status: Clear and cooperative
Level of Consciousness: Alert and oriented x3
Activity Status: Ambulatory with assistance

Discharge Instructions:
Dear Mr. ___,

You were admitted to the hospital because you had a bile duct
infection caused by a gallstone that got stuck in your bile duct.
This happened even though you had your gallbladder removed in the
past. We performed a procedure called ERCP to remove the stone
and open the bile duct. After this procedure, you developed
inflammation of your pancreas, which is a known risk of the
procedure. You also had some bleeding from the procedure site,
which required another scope to stop the bleeding and a blood
transfusion. Your kidney function worsened initially but improved
with fluids.

IMPORTANT CHANGES:
- Your insulin dose has been INCREASED to 28 units at bedtime
- Your metformin has been STOPPED until your kidney doctor clears
  you to restart it
- Your lisinopril has been DECREASED to 5mg
- Your pantoprazole has been INCREASED to twice a day
- Your aspirin has been HELD - ask your PCP when to restart
- You are on antibiotics until ___

Please follow up with your PCP in 1 week for INR check and to
review your medications. Follow up with GI in 2-4 weeks. Follow
up with your kidney doctor in 2 weeks.

If you develop fever, worsening abdominal pain, blood in your
stool, dark tarry stool, or vomiting blood, return to the ED
immediately.

Followup Instructions:
___
