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NYU Medicine Grand Rounds
Clinical Vignette
Himali Weerahandi, PGY3
March 6, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 37 year-old woman presenting with
abdominal pain for three months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•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.
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.
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.
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC, Basic Metabolic and Hepatic panels
were all within normal limits
•Helicobacter stool antigen was negative
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
•
•
•
•
Gastroesophageal reflux
Gastritis
Peptic ulcer disease
Cholelithiasis
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.
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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Symptomatic cholelithiasis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS