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SERVICE: General Surgery
REASON FOR CONSULTATION: Possible cholecystitis.
HISTORY OF PRESENT ILLNESS: This patient is a 48-year-old male status
post recent back surgery, who was admitted on 08/12/2012 due to shortness
of breath. The patient ended up becoming septic and had respiratory
failure, requiring mechanical ventilation. He was found to have bilateral
pneumonia. The patient also had acute renal failure, which has been
resolving, as well as uncontrolled blood sugars, which are also under
better management. The patient has been in the Intensive Care Unit
throughout the hospital course and was found on imaging studies, on a
recent CT scan of the torso, to have sludge within the gallbladder as well
as significant steatosis. This prompted a right upper quadrant ultrasound
on August 13th, which did show sludge in the gallbladder, some wall
thickening to 0.5 cm, as well as trace pericholecystic fluids. The
findings were equivocal for acute cholecystitis and therefore, a HIDA scan
was ordered. However, due to the patient's relative instability and
difficulty in undergoing a HIDA scan, this HIDA scan as been postponed.
Consultation has been obtained from Dr E due to his relationship
with the family, performance of surgery on the patient, and a temporal
artery biopsy in June, and they would like Dr E to evaluate the
patient.
PAST MEDICAL HISTORY: Diabetes, hypothyroidism, hypertension.
PAST SURGICAL HISTORY: Appendectomy, hernia repair, lumbar fusion,
temporal artery biopsy by Dr E in June 2012.
SOCIAL HISTORY: No alcohol, tobacco, or drug use. The patient lives with
his spouse.
FAMILY HISTORY: Noncontributory.
ALLERGIES: PENICILLIN.
MEDICATIONS IN THE HOSPITAL: Lantus, meropenem, Zithromax, vancomycin.
For further medications, please see the medication reconciliation.
PHYSICAL EXAMINATION: Temperature 37.8, heart rate 104, blood pressure
103/59, respiratory rate 18, saturating 99% on full vent support. The
patient is sedated and on the ventilator. The patient has coarse breath
sounds bilaterally as well as some rhonchi. Breath sounds are equal
bilaterally. Heart tachycardic. No appreciable murmur. Abdomen is soft,
mildly distended, nontender, bowel sounds positive. Extremities, bilateral
lower extremity edema. SCDs in place. Extremities are warm.
LABORATORY DATA: White blood cell count of 7.1, neutrophils 72.6%.
Bilirubin level 0.6, alkaline phosphatase 139, AST elevated at 81, ALT
elevated at 102. Glucose level currently 213.
IMAGING STUDIES: As noted above, a CT scan on August 13th shows sludge
within the gallbladder as well as possible calculi. No evidence of biliary
ductal dilation. An ultrasound also done on the 13th did show hepatomegaly
with diffuse hepatic steatosis, gallbladder sludge within the gallbladder,
as well as wall thickening and trace pericholecystic fluid, equivocal for
acute cholecystitis.
ASSESSMENT: A 48-year-old male with multiple medical issues, including
acute respiratory failure, possible acute respiratory distress syndrome,
bilateral pneumonia, and sepsis with findings of cholelithiasis and
possible cholecystitis.
PLAN: Due to the patient's current state, surgery would not be
recommended at this time, as the patient is too unstable. HIDA scan would
be preferable to rule out cholecystitis; however, since this is not an
option at this time, we would recommend the patient receive a repeat
ultrasound to evaluate the gallbladder and evaluate for any changes. If
the gallbladder has worsened since the ultrasound was performed on the
13th, percutaneous cholecystotomy tube would be indicated for
decompression. The findings and the patient were discussed with attending,
Dr B, who is covering for Dr E over the weekend.
Dr E will be following along with the patient as well, and these
findings will also be discussed with Dr E.
SERVICE: General Surgery
REASON FOR CONSULTATION: Possible cholecystitis.
HISTORY OF PRESENT ILLNESS: This patient is a 48-year-old male status
post recent back surgery, who was admitted on 08/12/2012 due to shortness
of breath. The patient ended up becoming septic and had respiratory
failure, requiring mechanical ventilation. He was found to have bilateral
pneumonia. The patient also had acute renal failure, which has been
resolving, as well as uncontrolled blood sugars, which are also under
better management. The patient has been in the Intensive Care Unit
throughout the hospital course and was found on imaging studies, on a
recent CT scan of the torso, to have sludge within the gallbladder as well
as significant steatosis. This prompted a right upper quadrant ultrasound
on August 13th, which did show sludge in the gallbladder, some wall
thickening to 0.5 cm, as well as trace pericholecystic fluids. The
findings were equivocal for acute cholecystitis and therefore, a HIDA scan
was ordered. However, due to the patient's relative instability and
difficulty in undergoing a HIDA scan, this HIDA scan as been postponed.
Consultation has been obtained from Dr E due to his relationship
with the family, performance of surgery on the patient, and a temporal
artery biopsy in June, and they would like Dr E to evaluate the
patient.
PAST MEDICAL HISTORY: Diabetes, hypothyroidism, hypertension.
PAST SURGICAL HISTORY: Appendectomy, hernia repair, lumbar fusion,
temporal artery biopsy by Dr E in June 2012.
SOCIAL HISTORY: No alcohol, tobacco, or drug use. The patient lives with
his spouse.
FAMILY HISTORY: Noncontributory.
ALLERGIES: PENICILLIN.
MEDICATIONS IN THE HOSPITAL: Lantus, meropenem, Zithromax, vancomycin.
For further medications, please see the medication reconciliation.
PHYSICAL EXAMINATION: Temperature 37.8, heart rate 104, blood pressure
103/59, respiratory rate 18, saturating 99% on full vent support. The
patient is sedated and on the ventilator. The patient has coarse breath
sounds bilaterally as well as some rhonchi. Breath sounds are equal
bilaterally. Heart tachycardic. No appreciable murmur. Abdomen is soft,
mildly distended, nontender, bowel sounds positive. Extremities, bilateral
lower extremity edema. SCDs in place. Extremities are warm.
LABORATORY DATA: White blood cell count of 7.1, neutrophils 72.6%.
Bilirubin level 0.6, alkaline phosphatase 139, AST elevated at 81, ALT
elevated at 102. Glucose level currently 213.
IMAGING STUDIES: As noted above, a CT scan on August 13th shows sludge
within the gallbladder as well as possible calculi. No evidence of biliary
ductal dilation. An ultrasound also done on the 13th did show hepatomegaly
with diffuse hepatic steatosis, gallbladder sludge within the gallbladder,
as well as wall thickening and trace pericholecystic fluid, equivocal for
acute cholecystitis.
ASSESSMENT: A 48-year-old male with multiple medical issues, including
acute respiratory failure, possible acute respiratory distress syndrome,
bilateral pneumonia, and sepsis with findings of cholelithiasis and
possible cholecystitis.
PLAN: Due to the patient's current state, surgery would not be
recommended at this time, as the patient is too unstable. HIDA scan would
be preferable to rule out cholecystitis; however, since this is not an
option at this time, we would recommend the patient receive a repeat
ultrasound to evaluate the gallbladder and evaluate for any changes. If
the gallbladder has worsened since the ultrasound was performed on the
13th, percutaneous cholecystotomy tube would be indicated for
decompression. The findings and the patient were discussed with attending,
Dr B, who is covering for Dr E over the weekend.
Dr E will be following along with the patient as well, and these
findings will also be discussed with Dr E.