tokens: Admission Date : 2011-01-19 Discharge Date : 2011-01-25 Date of Birth : 1943-01-22 Sex : M Service : MEDICINE INDICATION FOR ADMISSION : Transfer from Rehab Hospital of the Cape & Islands Hospital for an endoscopic retrogram cholangiopancreatography . HISTORY OF PRESENT ILLNESS : Mr. Eugene is a 67 year old male with a remote history of chronic pancreatitis due to alcohol abuse 30 years ago , who is transferred now from Rehab Hospital of the Cape & Islands Hospital for an ERCP and work-up for a cystic lesion at the head of his pancreas on CT scan shown at the outside hospital . The patient presented initially to Rehab Hospital of the Cape & Islands Hospital at the end of December for abdominal pain , and was found to have pancreatitis . During this admission , two CT scans had shown a question of an enlargement of the head of his pancreas versus early pseudocyst . The patient was discharged home early from this admission due to family needs . While at home , the patient did not do well and could tolerate minimal food intake and lost about 20 pounds in one month . On an office visit on 01-14 , the patient was found to have significantly elevated alkaline phosphatase . That evening , the patient again developed abdominal pain " like his pancreatitis " with nausea and vomiting , for which he was admitted to the Rehab Hospital of the Cape & Islands Hospital . In the Emergency Department at the Rehab Hospital of the Cape & Islands Hospital , the patient was noted to have vomited some heme positive material . His complete blood count showed 11% bandemia with a total white count of 10 . A HIDA scan showed no flow , question of pancreatitis versus common bile duct obstruction . His electrocardiogram showed a normal sinus rhythm . A chest x-ray was unremarkable . During his admission to Rehab Hospital of the Cape & Islands Hospital , the patient had dropped his hematocrit to the 30 s with recorded melena . He received an MRCP which was negative for evidence of stones . An ultrasound showed normal gallbladder with no wall thickening but a dilated common bile duct of 8 mm measured on CT scan . The patient had an attempted ERCP on 01-18 , which was unsuccessful due to a long nipple like papilla . He was therefore transferred to Saints Medical Center for endoscopic retrogram cholangiopancreatography . The patient 's blood cultures at outside hospital grew out Streptococcus sanguis-gordonii on 01-18 . This was sensitive to Clindamycin , Erythromycin , penicillin S and Vancomycin . Prior to this result , the patient had already been on Ampicillin , Sulbactam and Gentamycin . It appears from the Discharge summary that the patient was placed on Unasyn 3 grams intravenously every six hours after his ERCP . PAST MEDICAL HISTORY : 1. Type 2 diabetes mellitus . 2. Right rotator cuff injury . 3. Gastroesophageal reflux disease with esophageal dilatation for stricture . 4. Recent pancreatitis ; prior history for recurrent pancreatitis 30 years ago from alcohol . 5. History of Streptococcemia in the year 2008 ; source was unclear but presumed to be urinary . 6. Status post tonsillectomy as a child . MEDICATIONS AT HOME : 1. Prilosec 20 mg p.o. q. day . 2. Flomax 4 mg p.o. q. day . 3. Humalog 75/25 , subcutaneously . 4. Regular insulin 15 units q. a.m. and 14 units q. p.m. MEDICATIONS ON ADMISSION FROM TRANSFER : 1. Unasyn 3 grams intravenous every six hours . 2. NPH 10 units subcutaneously every morning and 8 units subcutaneously every evening . 3. Flomax 0.4 mg p.o. q. day . 4. Prilosec 30 mg p.o. q. day . 5. Regular insulin sliding scale . 6. Tylenol . ALLERGIES : The patient is allergic to Ciprofloxacin , morphine sulfate and Droperidol . SOCIAL HISTORY : The patient lives with his disabled wife who has a psychiatric condition . He had a history of alcohol abuse but has been sober for 30 years . He is a retired painter . PHYSICAL EXAMINATION : On admission showed a temperature of 97.1 F. ; heart rate of 65 ; blood pressure of 146/74 ; respiratory rate of 20 ; oxygen saturation 98% on three liters and 95% on room air . The patient was alert , awake and oriented , pleasant , and in no acute distress . Head , eyes , ears , nose and throat examination revealed mucous membranes that were moist . The patient has two teeth . He has fine dental hygiene . He had no icterus . Cardiovascular system revealed normal S1 and S2 , no murmurs or gallops and regular rate and rhythm . Pulmonary examination revealed lungs clear to auscultation bilaterally . Abdominal examination revealed an abdomen that is nondistended , nontender . He had normoactive bowel sounds . His liver span was 8 cm . The antrum was palpable 3 cm below the costal margin . The spleen tip was palpable . There was no rebound ; no Munos sign . Extremities reveal no edema , no swelling . Neurologic examination revealed an alert and oriented individual . His face was symmetric ; tongue was midline . His language was fluent and normal . The patient was moving all four extremities with ease . There was no formal strength test done . LABORATORY : Studies revealed a hematocrit of 32.6 , white count of 6.0 . His platelet count was 267 . His MCV was 88 , red cell distribution was 13.4 . Chemistry on admission showed a sodium of 141 , potassium of 4.3 , chloride of 107 , bicarbonate of 25 , BUN of 4 , creatinine of 0.6 and a sugar of 177 . Liver function tests revealed an ALT of 31 , AST of 36 , alkaline phosphatase of 509 . Total bilirubin was 0.8 . Albumin was 2.6 . His blood cultures were drawn and pending . Urinalysis revealed trace glucose , no ketones , no red cells , no white cells and less than one epithelial cells . COURSE IN HOSPITAL : The patient was taken down to the endoscopic retrogram cholangiopancreatogram upon admission . On this examination , the patient was found to have mild biliary stricture most likely secondary to chronic pancreatitis . Cytology was obtained . He was also found to have dilated pancreatic ducts with calcifications consistent with chronic pancreatitis . The patient underwent a percutaneous sphincterotomy extended to a full sphincterectomy . He also had successful extraction of stone fragments . The patient tolerated this procedure well and had no complications . The patient subsequently underwent a CT scan angiogram with Pancreas protocol to assess the pseudocyst versus enlarged pancreas head . The results of this study indicated that this structure at the head of his pancreas is most likely a forming pseudocyst ; however , the suspicion of malignancy is still possible and the patient underwent an ultrasound guided biopsy of this mass on 2011-01-20 . The cytology for this biopsy is still pending . The patient recovered well status post these two procedures . He had no complications and no subsequently pancreatitis . His alkaline phosphatase and all the other abnormal liver function tests were resolving . He had no pain and did not require any pain medications . He was tolerating food very well and was afebrile throughout admission . With regards to the patient 's documented Strep septicemia in the outside hospital , the Infectious Disease Team was formally consulted . Upon obtaining more information from Rehab Hospital of the Cape & Islands Hospital , it appears that the patient had two out of four bottles growing out Streptococcus sanguis in the outside hospital . The patient appeared to have been covered by Ampicillin , Gentamycin and then Unasyn in the outside hospital . The patient , on admission , was placed on Ampicillin , Gentamycin and Flagyl . With repeated blood cultures that were negative , the patient was reduced to single Mckenzie of intravenous Ampicillin . For this documented septicemia , this patient went for a endocarditis work-up . He had a transthoracic echocardiogram which revealed no vegetations . On this echocardiogram , he was found to have mildly dilated left atrium , mild symmetric left ventricular hypertrophy , and a normal ejection fraction of greater than 55% . There were no other abnormalities noted on this study . The patient then underwent a transesophageal echocardiogram on 01-24 . On this echocardiogram , he was again noted to not have any evidence for valvular vegetations . A complex plaque was found in the aortic arch in the descending thoracic aorta , although this plaque is non-mobile . There was focal mitral valve prolapse noted without pathologic mitral regurgitation . The patient was noted to have trace aortic regurgitation . A Panorex x-ray of his two teeth were obtained and a Dental Consultation was done . The patient was thought to have normal dental hygiene and low suspicion for a source of his alpha septicemia from his mouth . Infectious Disease Department as well as Cardiology had recommended a formal 14 - day course of intravenous antibiotics to treat a documented alpha Streptococcal septicemia from outside hospital blood cultures . The patient 's insurance company , however , would not pay for home antibiotics . After much discussion with the patient , the patient was informed of the risks of not finishing a 14 day course of intravenous antibiotics and chose to go home . He had three days of antibiotics remaining at the time of discharge . It was discussed with the patient to send him out on Augmentin 500 mg three times a day for ten more days . He was to follow-up with his primary care physician within two to three days for repeat laboratory studies and blood cultures . He was to return to the hospital with any signs of shaking chills or fever . DISCHARGE DIAGNOSES : 1. Pancreatitis status post endoscopic retrogram cholangiopancreatography and sphincterotomy . 2. Alpha Streptococcus septicemia . DISCHARGE MEDICATIONS : 1. Augmentin 500 mg p.o. three times a day times ten days . 2. Flomax 0.4 mg p.o. q. day . 3. Prilosec 20 mg p.o. q. day . 4. Humalog and Regular insulin subcutaneously . Hallo MING LI , M.D. 40-963 Dictated By : Annie D. Martinez , M.D. MEDQUIST36 D : 2011-01-25 14:08 T : 2011-01-26 11:30 JOB #: 09167 Signed electronically by : DR. Dorothy L. Brennan on : Russell 2011-01-27 11:38 AM ( End of Report )