NYU Medicine Grand Rounds Clinical Vignette

1. NYU Medicine Grand Rounds Clinical Vignette Himali Weerahandi, PGY3 March 6, 2012 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 37 year-old woman presenting with abdominal pain for three months.

3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Young woman in no acute distress • Vital Signs: T: 98.3 BP: 97/65 HR:64 RR:14 and O2 sat:100 % on room air • Physical exam was normal

9. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC, Basic Metabolic and Hepatic panels were all within normal limits • Helicobacter stool antigen was negative

10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis • Gastroesophageal reflux • Gastritis • Peptic ulcer disease • Cholelithiasis

11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS 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. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Symptomatic cholelithiasis