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NYU Medicine Grand Rounds Clinical Vignette

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NYU Medicine Grand Rounds Clinical Vignette Himali Weerahandi, PGY3 March 6, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 37 year-old woman presenting with ... – PowerPoint PPT presentation

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Title: NYU Medicine Grand Rounds Clinical Vignette


1
NYU Medicine Grand Rounds Clinical Vignette
  • Himali Weerahandi, PGY3
  • March 6, 2012

2
Chief Complaint
  • 37 year-old woman presenting with abdominal pain
    for three months.

3
History of Present Illness
  • The patient was previously in good health, until
    six months prior when she began experiencing
    intermittent burning epigastric pain for seven
    days, triggered after spicy meals.
  • She presented to an Urgent Care Clinic where she
    was diagnosed with gastroesophageal reflux and
    started on omeprazole 20mg daily.

4
History of Present Illness
  • Two months later, she re-presented to another
    medicine clinic with persistent symptoms.
  • During periods of post-prandial epigastric pain,
    she described intermittent nausea with a few
    episodes of nonbilious/nonbloody vomiting, and
    reflux symptoms.
  • She admitted that she was not taking the
    omeprazole as directed, a half hour before meals.
  • The patient was instructed to take the medication
    properly, and continued on the omeprazole.

5
History of Present Illness
  • One month later, the patient returned to clinic
    with persistence of symptoms. Although she
    reported mild improvement in reflux symptoms, she
    had worsening episodes of nausea, vomiting, and
    abdominal pain.
  • She also reported a two day period of subjective
    fevers and chills that resolved spontaneously.
  • Because of worsening symptoms, her omeprazole was
    increased to 40mg daily and she was referred to
    gastroenterology clinic for an upper endoscopy.

6
History of Present Illness
  • Before her scheduled gastroenterology
    appointment, she experienced severe worsening of
    abdominal pain with nausea and vomiting, she
    presented to the emergency room. There
    laboratory findings were reportedly normal, and
    her symptoms were treated and relieved after
    receiving a cocktail of several medications.
  • She was discharged and referred to Bellevue Adult
    Primary Care Walk-In Clinic for follow-up.

7
Additional History
  • Past Medical History
  • No previous medical history
  • Past Surgical History
  • No surgeries
  • Social History
  • Denies tobacco or alcohol use
  • Moved to the US from Thailand four years ago
  • Currently not working
  • Family History
  • Mother heart arrhythmia
  • Allergies
  • No Known Drug Allergies
  • Medications
  • Omeprazole 40 mg daily
  • Pepto-bismol

8
Physical Examination
  • General Young woman in no acute distress
  • Vital Signs T 98.3 BP 97/65 HR64 RR14 and
    O2 sat100 on room air
  • Physical exam was normal

9
Laboratory Findings
  • CBC, Basic Metabolic and Hepatic panels were all
    within normal limits
  • Helicobacter stool antigen was negative

10
Differential Diagnosis
  • Gastroesophageal reflux
  • Gastritis
  • Peptic ulcer disease
  • Cholelithiasis

11
Further Diagnostic Tests
  • Right-upper quadrant abdominal ultrasound
  • Distended gallbladder packed with innumerable
    gallstones.
  • No evidence of gall bladder wall thickening or
    fluid collections suggestive of cholecystitis.

12
Outpatient Course
  • The patient was referred to general surgery
    clinic where she was evaluated and underwent
    elective cholecystectomy.
  • She is currently without symptoms and no longer
    requires treatment with omeprazole.

13
Final Diagnosis
  • Symptomatic cholelithiasis
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