Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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Clinical Correlations The NYU Internal Medicine
BlogA Daily Dose of Medicine
http//clinicalcorrelations.org
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Department of Medicine Grand RoundsClinical
Vignette

• Abe Khan
• January 7th, 2009
• NYU Langone Medical Center
• Internal Medicine Residency Program

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Chief Complaint

• The patient is a 36 year old Hispanic female who
  presented with 10 days of abdominal pain.

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History of Present Illness

• Her pain began intermittently, 10 days prior to
  presentation
• Her pain was primarily in the right upper
  quadrant and did not radiate, but did worsen with
  food intake
• 3 days prior to admission, she began to have
  subjective fevers
• 1 day prior to admission, she developed nausea
  and vomiting

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Additional History

• Past Medical History none
• Past Surgical History none
• Social History denies toxic habits
• Family History non-contributory
• Allergies no known drug allergies
• Medications Albuterol inhaler as needed

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Physical Exam

• General Middle-aged female in moderate distress,
  mildly obese
• Vital Signs T- 97.2, HR- 99, BP- 97/64, RR-16
• Abdominal mild tenderness to palpation in the
  right upper quadrant
• The remainder of the physical exam was negative

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Laboratory

• WBC 14.4 with 19 bands
• AST 435 (11-39)
• ALT 883 (11-35)
• Alkaline Phosphatase 304 (25-100)
• Total bilirubin 3 (0.2-1.3)
• Direct bilirubin 2.2 (0-0.2)
• Lipase normal
• Amylase 280 (35-150)
• Urinalysis 3 bilirubin, positive nitrite and
  leuckocyte esterase, 10-15 WBC

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Differential Diagnosis

• Acute Viral Hepatitis
• Cholangitis
• Urinary Tract Infection

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Hospital Course

• Hospital Day 1
• Bedside abdominal ultrasound
• Multiple mobile gallstones, common bile duct
  (CBD) 4 mm and normal, no evidence of
  cholecystitis
• Patient admitted and started on IV fluids and
  ampicillin/sulbactam.
• Hospital Day 2
• CT Abdomen / Pelvis with contrast
• Multiple gallstones and several within CBD,
  mildly distended CBD to 1 cm, and a small amount
  of pericholecystic fluid

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Hospital Course

• Hospital Day 3
• ERCP
• Multiple filling defects in the mid and distal
  CBD. A sphincterotomy was done and a stent
  placed. Sludge retrieved, but CBD stones could
  not be completely removed.
• Operating Room
• Laparoscopic cholecystectomy performed.
• Hospital Day 6
• Operating Room Laparoscopic cholecystectomy
  performed
• Hospital Day 7
• -Post-operative course unremarkable.
• -Pain and laboratory findings improved
• -Pathology from operating room returned as
  normal gallbladder with cholesterol stones within
  the gallbladder, largest measuring 1cm

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Final Diagnosis

• Choledocolithiasis, cholesterol-containing stones