tokens: Admission Date : 2013-05-14 Discharge Date : 2013-05-18 Date of Birth : 1953-07-27 Sex : F Service : CMED CSRU CHIEF COMPLAINT : The patient was admitted originally for airway monitoring status post endoscopic retrograde cholangiopancreatography with adverse reaction to Fentanyl and tongue injury . HISTORY OF PRESENT ILLNESS : The patient is a 59 year-old female status post endoscopic retrograde cholangiopancreatography on the day of admission , which had been done to evaluate for possible bile leak after cholecystectomy was performed four days ago . The patient was in her usual state of health until four days prior to admission when she had a cholecystectomy . Her postop course was uneventful until one day prior to admission when she developed abdominal pain . She went to an outside hospital Emergency Room and was reassured and sent home . On the day of admission she returned to the outside hospital Emergency Room where an abdominal CT was performed , which showed " thickened stomach and free air ." She was sent to New England Sinai Hospital & Rehab Center for an endoscopic retrograde cholangiopancreatography and possible stent placement . She had a successful endoscopic retrograde cholangiopancreatography , which showed a bile leak at the duct of Luschka . A stent was placed successfully . After her endoscopic retrograde cholangiopancreatography the patient developed " jaw clenching , biting tongue , rigidity and cold / chills ." The patient received ampicillin , Gentamycin and Flagyl empirically as well as Narcan to reverse fentanyl . Because of the tongue injury and tachycardia as well as possible infection given her fevers or chills the GI Service transferred the patient to the CMED CCU for close observation . PAST MEDICAL HISTORY : 1. Hiatal hernia . 2. Status post cholecystectomy four days prior to admission . 3. Urinary frequency secondary to interstitial cystitis . 4. Mitral valve prolapse . 5. Tubal ligation many years ago . MEDICATIONS ON ADMISSION : 1. Prempro . 2. CMED CCU drops . ALLERGIES : No known drug allergies at the time of admission , however , it is assumed that her rigidity and jaw clenching was secondary to Fentanyl . SOCIAL HISTORY : The patient is married . She works as a teacher 's aid in Cambridge . She denies tobacco or alcohol use . PHYSICAL EXAMINATION ON ADMISSION TO THE CMED CCU : Vital signs temperature 100.6 . Heart rate 105 . Blood pressure 162/76 . Respiratory rate 18 . Sating 98% on 3 liters . In general , the patient was groggy status post anesthesia , shivering , but awake . HEENT showed tongue with laceration on the right edge . Mucous membranes are moist . Pupils are equal , round and reactive to light . Extraocular movements intact . Lungs were clear to auscultation bilaterally . Heart regular rate and rhythm . No murmurs , rubs or gallops . Abdomen was soft , nontender , nondistended . There were normoactive bowel sounds . There was no rebound or guarding . There were post laparoscopic incisions without erythema with Steri-Strips in place . The extremities were without edema . Dorsalis pedis pulses were intact bilaterally . There were no rashes . LABORATORIES ON ADMISSION : White blood cell count 9.0 , hematocrit 39.3 , platelets 296 , neutrophil count 82 , lymphocytes 14 , 4 monocytes , troponin was less then 0.3 . Sodium 139 , potassium 3.8 , chloride 101 , bicarb 26 , BUN 9 , creatinine 0.7 , glucose 141 , albumin 4.1 , calcium 8.9 , LDH 665 , AST 44 , ALT of 57 , amylase 41 , CK 32 . Electrocardiogram showed normal sinus rhythm at 73 beats per minute . There was normal axis . Normal intervals . There were no ST or T wave changes . Abdominal CT showed inflammation in the right upper quadrant , small fluid in the circumferential thickening of the distal stomach . There was a question of a small ulcer . There was a tiny amount of free air . This was per report of Vencor Hospital . HOSPITAL COURSE : In summary the patient is a 59 year-old female who was admitted to Quincy Medical Center for an endoscopic retrograde cholangiopancreatography for possible stent placement for a bile leak secondary to cholecystectomy performed four days prior to admission . She then suffered rigidity with jaw clenching and tongue biting secondary to Fentanyl administration and was transferred to the CMED CCU for close observation . She did well overnight in the CMED CCU . She was started on Ampicillin , Gentamycin and Flagyl . Her liver function tests and amylase and lipase were followed closely . On the second hospital day the patient was doing much better and was stable from an airway perspective , so she was transferred to the General Medical Floor . 1. Gastrointestinal : As stated the patient was status post endoscopic retrograde cholangiopancreatography with stent placement for a bile leak from the duct of Luschka . The patient was continued on Ampicillin , Gentamycin and Flagyl , which had been started at the time of transfer to the CMED CCU . She had waxing and waning fevers . However , her white blood cell count was never really elevated and she did not have a bandemia . On the day of transfer to the General Medical Floor the patient had received clear liquids . She did not tolerate this very well . Her amylase and lipase on the day following the endoscopic retrograde cholangiopancreatography were elevated . Amylase was 2304 with lipase being 7116 . Therefore she was made NPO and given aggressive intravenous hydration . On the second hospital day on the General Medical Floor the patient had marked rebound to palpation of her abdomen . She was followed closely with serial abdominal examinations . Her amylase and lipase were trending down , however . An abdominal CT was obtained , which showed only mild pancreatitis . There were no intra-abdominal fluid collections , which required any drainage . On the third hospital day the patient 's pain was improving and the rebound was decreasing . Her enzymes continued to trend down . She received clear liquids in the evening and tolerated these well . On the day of discharge the patient was tolerating a BRAT diet without significant abdominal pain . She had no further rebound . She had no temperature spikes in greater then 24 hours at the time of discharge . 2. Hematology : The patient 's hematocrit was 34.8 at the time of admission . It decreased to 30 in the setting of aggressive hydration . It remained stable at the time of discharge and it was 29.5 on the day of discharge . 3. FEN : The patient was aggressively hydrated given that she was NPO . She required periodic repletion of her potassium . Her bicarb began to drop and she developed an anion gap acidosis . This was most likely secondary to ketoacidosis as she had no dextrose in her intravenous fluids . This was added on the evening prior to discharge and on the day of discharge her anion gap acidosis had resolved . CONDITION ON DISCHARGE : Stable . MEDICATIONS ON DISCHARGE : 1. Levaquin 500 mg one po q day times seven days . 2. Protonix 40 mg po q day . 3. Percocet one to two tablets po q 4 to 6 hours prn . The patient was given a prescription for ten pills . 4. Prempro as the patient was formerly taking . 5. Trazodone at bedtime . DISCHARGE FOLLOW UP : The patient was to make an appointment with Dr. Nicholson within one to two months after discharge for removal of the stent . In addition , she would follow up with her primary care physician within one to two weeks following discharge . She was to continue on a BRAT diet over the weekend and two days after discharge she could advance to a low fat no dairy diet . She could slowly advance back to a normal diet over the next week . DISCHARGE DIAGNOSES : 1. Post endoscopic retrograde cholangiopancreatography pancreatitis . 2. Anemia . 3. Hypokalemia . 4. Anion gap acidosis . 5. Bile leak . Thompson MING LI , M.D. 44-725 Dictated By : Marcelene R. Brennan , M.D. MEDQUIST36 D : 2013-05-18 13:49 T : 2013-05-20 08:16 JOB #: 23220 Signed electronically by : DR. Ruth O. Black on : WED 2013-05-22 7:10 AM ( End of Report )