ImranzamanML/Clinical_Documents_on_Syndromes_Disease

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Acute gangrenous cholecystitis with cholelithiasis.

OPERATION PERFORMED:

Laparoscopic cholecystectomy with cholangiogram.

FINDINGS:

The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

COMPLICATIONS:

None.

EBL:

Scant.

SPECIMEN REMOVED:

Gallbladder with stones.

DESCRIPTION OF PROCEDURE:

The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.
CC:

HA and vision loss.

HX:

71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.

FHX:

HTN

stroke, coronary artery disease, melanoma.

SHX:

Quit smoking 15 years ago.

MEDS:

Lanoxin, Capoten, Lasix, KCL

ASA

Voltaren, Alupent MDI

PMH:

CHF

Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.

EXAM:

35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS

Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e.

fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.

LAB:

CBC

PT/PTT

General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL

glucose 58mg/DL

RBC 2800/mm3, WBC 1/mm3. ANA

RF

TSH

FT4 were WNL.

IMPRESSION:

CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.

COURSE:

The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS

RAPD OS

bilateral optic disk pallor (OS > OD)

CN3 palsy and bilateral temporal field loss, OS >> OD . ESR

CRP

MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high)

Acute gangrenous cholecystitis with cholelithiasis.

OPERATION PERFORMED:

Laparoscopic cholecystectomy with cholangiogram.

FINDINGS:

The patient had essentially a dead gallbladder with stones and positive wide bile/pus coming from the gallbladder.

COMPLICATIONS:

None.

EBL:

Scant.

SPECIMEN REMOVED:

Gallbladder with stones.

DESCRIPTION OF PROCEDURE:

The patient was prepped and draped in the usual sterile fashion under general anesthesia. A curvilinear incision was made below the umbilicus. Through this incision, the camera port was able to be placed into the peritoneal cavity under direct visualization. Once this complete, insufflation was begun. Once insufflation was adequate, additional ports were placed in the epigastrium as well as right upper quadrant. Once all four ports were placed, the right upper quadrant was then explored. The patient had significant adhesions of omentum and colon to the liver, the gallbladder constituting definitely an acute cholecystitis. This was taken down using Bovie cautery to free up visualization of the gallbladder. The gallbladder was very thick and edematous and had frank necrosis of most of the anterior gallbladder wall. Adhesions were further taken down between the omentum, the colon, and the gallbladder slowly starting superiorly and working inferiorly towards the cystic duct area. Once the adhesions were fully removed, the cholangiogram was done which did not show any evidence of any common bile duct dilatation or obstruction. At this point, due to the patient's gallbladder being very necrotic, it was deemed that the patient should have a drain placed. The cystic duct and cystic artery were serially clipped and transected. The gallbladder was removed from the gallbladder fossa removing the entire gallbladder. Adequate hemostasis with Bovie cautery was achieved. The gallbladder was then placed into a bag and removed from the peritoneal cavity through the camera port. A JP drain was then run through the anterior port and out of one of the trochar sites and secured to the skin using 3-0 nylon suture. Next, the right upper quadrant was copiously irrigated out using the suction irrigator. Once this was complete, the additional ports were able to be removed. The fascial opening at the umbilicus was reinforced by closing it using a 0 Vicryl suture in a figure-of-8 fashion. All skin incisions were injected using Marcaine 1/4 percent plain. The skin was reapproximated further using 4-0 Monocryl sutures in a subcuticular technique. The patient tolerated the procedure well and was able to be transferred to the recovery room in stable condition.

CC:

HA and vision loss.

HX:

71 y/o RHM developed a cataclysmic headache on 11/5/92 associated with a violent sneeze. The headache lasted 3-4 days. On 11/7/92, he had acute pain and loss of vision in the left eye. Over the following day his left pupil enlarged and his left upper eyelid began to droop. He was seen locally and a brain CT showed no sign of bleeding, but a tortuous left middle cerebral artery was visualized. The patient was transferred to UIHC 11/12/92.

FHX:

HTN

stroke, coronary artery disease, melanoma.

SHX:

Quit smoking 15 years ago.

MEDS:

Lanoxin, Capoten, Lasix, KCL

ASA

Voltaren, Alupent MDI

PMH:

CHF

Atrial Fibrillation, Obesity, Anemia, Duodenal Ulcer, Spinal AVM resection 1986 with residual T9 sensory level, hyperreflexia and bilateral babinski signs, COPD.

EXAM:

35.5C, BP 140/91, P86, RR20. Alert and oriented to person, place, and time. CN: No light perception OS

Pupils: 3/7 decreasing to 2/7 on exposure to light (i.e.

fixed/dilated pupil OS). Upon neutral gaze the left eye deviated laterally and inferiorly. There was complete ptosis OS. On downward gaze their was intorsion OS. The left eye could not move superiorly, medially or effectively downward, but could move laterally. EOM were full OD. The rest of the CN exam was unremarkable. Motor, Coordination, Station and Gait testing were unremarkable. Sensory exam revealed decreased pinprick and light touch below T9 (old). Muscle stretch reflexes were increased (3+/3+) in both lower extremities and there were bilateral babinski signs (old). The upper extremity reflexes were symmetrical (2/2). Cardiovascular exam revealed an irregularly irregular rhythm and lung sounds were coarse bilaterally. The rest of the general exam was unremarkable.

LAB:

CBC

PT/PTT

General Screen were unremarkable except for a BUN 21mg/DL. CSF: protein 88mg/DL

glucose 58mg/DL

RBC 2800/mm3, WBC 1/mm3. ANA

RF

TSH

FT4 were WNL.

IMPRESSION:

CN3 palsy and loss of vision. Differential diagnosis: temporal arteritis, aneurysm, intracranial mass.

COURSE:

The outside Brain CT revealed a tortuous left MCA. A four-vessel cerebral angiogram revealed a dolichoectatic basilar artery and tortuous LICA. There was no evidence of aneursym. Transesophageal Echocardiogram revealed atrial enlargement only. Neuroopthalmologic evaluation revealed: Loss of color vision and visual acuity OS

RAPD OS

bilateral optic disk pallor (OS > OD)

CN3 palsy and bilateral temporal field loss, OS >> OD . ESR

CRP

MRI were recommended to rule out temporal arteritis and intracranial mass. ESR 29mm/Hr, CRP 4.3mg/DL (high)