IM H&P 3

Chief Complaint
Abdominal pain with nausea and vomiting.

History of Present Illness
 68-year-old female with a past medical history significant for coronary artery disease  status post percutaneous coronary intervention  with drug-eluting stents (DES) x3, hypertension , hyperlipidemia , diabetes mellitus , and an implantable cardioverter-defibrillator  with a prior ejection fraction  of 35-40%. She presented to the emergency department  with abdominal pain associated with nausea and vomiting for one day. The patient reported that her pain started at 11 p.m. the previous night and worsened abruptly in the morning after eating breakfast. She described the pain as sharp and cramping, localized to the right upper quadrant of the abdomen. Patient rates pain at 9/10 and states it has been constant since the meal she ate this morning consisting of rice and chicken. She states she had two episodes of non-bloody, non-bilious emesis following the onset of pain.She denied taking any medications for pain but stated she was given aspirin by EMS. She denied fever, chest pain, or shortness of breath.

The patient was admitted on 10/15/2024 for non-operative management of acute cholecystitis (hospital day 3). She reports that she feels much better today, with resolution of her abdominal pain after starting antibiotics. She is passing gas but has not had a bowel movement today. She denies any nausea or vomiting overnight.

DDX:

  • Cholecystitis
  • MI
  • Acute Pancreatitis
  • Nephrolithiasis

Past Medical History

  • Hypertension
  • Diabetes Mellitus
  • Hyperlipidemia (HLD)
  • Ischemic cardiomyopathy (ICM)
  • Coronary artery disease (CAD): History of right and left heart catheterizations
    • Proximal to mid LAD stented on 11/16/2023
    • Distal RCA stented on 09/18/2024

Medications

  • Aspirin 81 mg daily
  • Atorvastatin 80 mg daily (bedtime)
  • Alirocumab 75 mg/ml solution, 1 injection subcutaneously every 14 days
  • Furosemide 40 mg daily
  • Ezetimibe 10 mg daily
  • Janumet 50-500 mg daily
  • Dapagliflozin 10 mg daily
  • Metoprolol succinate 25 mg daily
  • Sacubitril-valsartan 49-51 mg orally
  • Ticagrelor 90 mg twice daily

Surgical History

  • Cardiac Catheterization (11/16/2023)

Allergies

  • No known drug, food, or environmental allergies

Family History

  • Mother: Deceased at age 88
  • Father: Deceased at age 90
  • Siblings: None reported
  • Children: Daughter, a nurse at Mt. Sinai, in contact with the hospital

Social History

  • Smoking: Denies history of smoking
  • Alcohol: Denies alcohol intake
  • Illicit Drug Use: Denies
  • Marital Status: Married, lives with husband in an apartment in Flushing
  • Occupation: Housewife
  • Travel: No recent travel
  • Exercise: Occasional walks with her husband (3-4 times a week)
  • Diet: Primarily home-cooked Indian meals, with oily foods making up a majority of her diet

Review of Systems

  • General: Denies fever, chills, night sweats, or weight loss
  • Skin: Denies any skin changes, rashes, or bruising
  • HEENT: Denies headache, visual disturbances, or ear pain
  • Neck: Denies swelling or stiffness
  • Pulmonary: Denies cough, dyspnea, or wheezing
  • Cardiovascular: Denies chest pain, edema, or palpitations
  • Gastrointestinal: Denies current abdominal pain, Denies diarrhea/constipation 
  • Genitourinary: Denies dysuria or changes in urinary habits
  • Musculoskeletal: Denies muscle or joint pain
  • Nervous System: Denies weakness or changes in cognition
  • Peripheral Vascular: Denies cold extremities or swelling
  • Hematologic: Denies easy bruising or bleeding
  • Endocrine: Denies excessive thirst or hunger
  • Psychiatric: Denies depression or anxiety

Physical Exam

  • Vital Signs:
    • BP: 117/68 mmHg
    • HR: 70 bpm
    • RR: 16 breaths per minute
    • Temp: 36.5°C
    • O2 Sat: 98% on room air
    • Height: 157.5 cm
    • Weight: 59 kg
    • BMI: 23.78
  • General: 68-year-old female, alert, in no acute distress
  • HEENT: Normocephalic, atraumatic; pupils equal, round, and reactive to light and accommodation (PERRLA)
  • Neck: No lymphadenopathy; neck supple
  • Heart: Regular rate and rhythm, no murmurs
  • Lungs: Clear to auscultation bilaterally, no wheezes or crackles
  • Abdomen: Soft, non-tender, non-distended; normal bowel sounds in all quadrants; no guarding or rebound tenderness. Negative Murphy’s Sign 

Labs/Imaging:

Imaging:

  • XR Chest(AP)
    • Enlarged Cardiac Silhouette again noted.Borderline findings of pulmonary edema.
  • US Abdomen RUQ
    • Wall thickening, distended gallbladder with stones and pericholecystic fluid, which can be seen with acute cholecystitis. 
  • CT abdomen Pelvis with IV contrast
    • Cardiomegaly. Bibasilar subtle subpleural septal thickening, which may be seen with edema.Dependent gallstones within a distended and wall thickening gallbladder, suspicious for acute cholecystitis. 
    • Infrarenal abdominal aorta ulcerated plaque and floating soft plaques , contributing to mold to moderate stenosis.
    • Right adrenal gland 2.3 cm nodule. 

Laboratory Results:

Assessment and Plan

A/P

68-year-old female with a history of coronary artery disease status post PCI with drug-eluting stents, hypertension, hyperlipidemia, ischemic cardiomyopathy, diabetes mellitus, and chronic kidney disease . She presented with right upper quadrant abdominal pain, nausea, and vomiting, and was diagnosed with acute cholecystitis. After initiation of IV Zosyn, her symptoms have significantly improved, with resolution of pain and no recurrence of nausea or vomiting. Her abdominal exam now shows no tenderness or distension, and she is tolerating a regular diet. We will continue Zosyn and closely monitor LFTs and WBCs to ensure resolution of infection. Surgical consultation has been obtained, and the patient will be followed as an outpatient for elective cholecystectomy.

#Acute cholecystitis 

 Monitor fever, trend WBCs, LFTs

Follow-up blood cultures(NGTD)

Continue IV Zosyn

Surgery consulted, (no acute intervention outpatient follow-up to discuss elective cholecystectomy).

#Ischemic cardiomyopathy, chronic systolic CHF

Coronary artery disease status post PCI x3 , last  recently September 2024 

Hypertension – goal, normotensive

Hyperlipidemia -lipid panel

Continue home regimen of ASA, Atorvastatin, Farxiga, Zetia, Lasix, Entresto, Brillinta

#Incidental adrenal mass 

Outpatient follow-up CT abdomen adrenal mass protocol 

# Aortic plaque likely thrombus 

Vascular Surgery consulted (No acute vascular surgical intervention)

Continue  dual antiplatelets(aspirin, brilinta)

 #CKD 

Creatinine close at baseline

Avoid nephrotoxic med 

Monitor renal function 

#Diabetes mellitus with hyperglycemia 

Monitor blood sugar x4 

Insulin lispro sliding scale

 Diet:Carb controlled diet

Code Status: Full Code

 VTE Prophylaxis: lovenox SQ

Patient Education 

You have been diagnosed with acute cholecystitis, an inflammation of the gallbladder typically caused by gallstones blocking the bile duct, which has led to your abdominal pain, nausea, and vomiting. Right now, you are being treated with IV Zosyn, a broad-spectrum antibiotic to manage the infection, and we are monitoring your liver function tests and white blood cell count to ensure you continue to improve. Surgery may be considered later to remove your gallbladder, but for now, your treatment is non-surgical, and you should feel better over the next few days. To help prevent further gallbladder issues, it’s recommended that you avoid fatty or oily foods and maintain a balanced diet. If you notice any new or worsening abdominal pain, fever, nausea, vomiting, or yellowing of your skin or eyes, you should return to the hospital or contact your doctor immediately. Follow-up with surgery will be necessary to discuss potential elective gallbladder removal.