Other iatrogenic hypotension Chronic hepatitis C with hepatic coma Cachexia Hyposmolality and/or hyponatremia Other ascites Hyperpotassemia Tobacco use disorder Asymptomatic human immunodeficiency virus [HIV] infection status Do not resuscitate status Other dependence on machines supplemental oxygen Chronic airway obstruction not elsewhere classified Bipolar disorder unspecified Cirrhosis of liver without mention of alcohol
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Percocet / Vicodin
 
Attending: ___
 
Chief Complaint:
altered mental status
 
Major Surgical or Invasive Procedure:
none
 
History of Present Illness:
Mrs. ___ is a ___ female with HIV on HAART, COPD, HCV 
cirrhosis complicated by ascites and hepatic encephalopathy who 
initially presented to the ED yesterday with hypotension after a 
paracentesis.  
The patient has had accelerated decompensation of her cirrhosis 
recently with worsening ascites, and she is maintained on twice 
weekly paracentesis. She was at her regular session yesterday 
when she had hypotension to SBP ___ and felt lightheadedness. 
Per the patient, that's when her memory started to get fuzzy. 
She does not have much recollection of what happened since then. 
Her outpatient hepatologist saw her and recommended that she go 
to the ED. In the ED, she was evaluated and deemed to have 
stable blood pressure. She was discharged home. At home, she had 
worsening mental status with her daughter getting concerned, and 
she returned to the ED.  
In the ED, initial vitals were 98.7 77 96/50 16 98% RA. The 
patient was only oriented to person. Her labs were notable for 
Na 126, K 6.7, Cr 0.7 (baseline 0.4), ALT 153, AST 275, TBili 
1.9, Lip 66, INR 1.5. Initial EKG showed sinus rhythm with 
peaked T waves. Her head CT was negative for any acute 
processes. She received ceftriaxone 2gm x1, regular insulin 10U, 
calcium gluconate 1g, lactulose 30 mL x2, and 25g 5% albumin.  
On transfer, vitals were 99.0 93 84/40 16 95% NC. On arrival to 
the MICU, patient was more alert and conversant. She has no 
abdominal pain, nausea, vomiting, chest pain, or difficulty 
breathing. She has a chronic cough that is not much changed. She 
has not had any fever or chills. She reports taking all of her 
medications except for lactulose, which she thinks taste 
disgusting.  
 
Past Medical History:
- HCV Cirrhosis: genotype 3a  
- HIV: on HAART, ___ CD4 count 173, ___ HIV viral load 
undetectable  
- COPD: ___ PFT showed FVC 1.95 (65%), FEV1 0.88 (37%), 
FEFmax 2.00 (33%)  
- Bipolar Affective Disorder  
- PTSD  
- Hx of cocaine and heroin abuse  
- Hx of skin cancer per patient report  
 
Social History:
___
Family History:
She a total of five siblings, but she is not  talking to most of 
them. She only has one brother that she is in  touch with and 
lives in ___. She is not aware of any known GI or liver 
disease in her family.  
 
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals T: 98.7 BP: 84/48 P: 91 R: 24 O2: 98% NC on 2L  
GENERAL: Alert, oriented, no acute distress  
LUNGS: Decreased air movement on both sides, scattered 
expiratory wheezes  
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, 
gallops  
ABD: Soft, non-tender, distended, flank dullness bilaterally, 
bowel sounds present  
EXT: Warm, well perfused, 2+ pulses, no cyanosis or edema  

DISCHARGE PHYSICAL EXAM:
Vitals- Tm 99.5, Tc 98.7, ___ 79-96/43-58 20 95% on 3L NC, 
7BM.  
General- Cachectic-appearing woman, alert, oriented, no acute 
distress  
HEENT- Sclera anicteric, MMM, oropharynx clear, poor dentition 
with partial dentures  
Neck- supple, JVP not elevated, no LAD  
Lungs- Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, 
gallops  
Abdomen- Mildly distended and firm, non-tender, bowel sounds 
present, no rebound tenderness or guarding  
GU- no foley  
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or 
edema  
Neuro- AOx3, No asterixis.  
 
Pertinent Results:
ADMISSION LABS:
=================
___ 06:39AM BLOOD WBC-6.9 RBC-3.98* Hgb-14.1 Hct-41.1 
MCV-103* MCH-35.4* MCHC-34.3 RDW-15.8* Plt ___
___ 06:39AM BLOOD Neuts-72.7* Lymphs-14.7* Monos-9.8 
Eos-2.5 Baso-0.3
___ 06:39AM BLOOD ___ PTT-32.4 ___
___ 06:39AM BLOOD Glucose-102* UreaN-49* Creat-0.7 Na-126* 
K-6.7* Cl-95* HCO3-25 AnGap-13
___ 06:39AM BLOOD ALT-153* AST-275* AlkPhos-114* 
TotBili-1.9*
___ 06:39AM BLOOD Albumin-3.6

IMAGING/STUDIES:
================
___ CT HEAD:
No evidence of acute intracranial process.
The left zygomatic arch deformity is probably chronic as there 
is no
associated soft tissue swelling.

___ CXR:
No acute intrathoracic process.

DISCHARGE LABS:
===============
___ 04:45AM BLOOD WBC-4.8 RBC-3.15* Hgb-11.2* Hct-32.1* 
MCV-102* MCH-35.4* MCHC-34.8 RDW-15.8* Plt Ct-95*
___ 04:45AM BLOOD ___ PTT-37.6* ___
___ 04:45AM BLOOD Glucose-121* UreaN-35* Creat-0.4 Na-130* 
K-5.2* Cl-97 HCO3-27 AnGap-11
___ 04:45AM BLOOD ALT-96* AST-168* AlkPhos-69 TotBili-1.7*
___ 04:45AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.___ w/ HIV on HAART, COPD on 3L home O2, HCV cirrhosis 
decompensated (ascites requiring biweekly therapeutic 
paracenteses, hepatic encephalopathy; not on transplant list ___ 
comorbidities) w/ AMS, hypotension, ___, and hyperkalemia. 
Altered mental status improved with lactulose. Hypotension was 
felt to be due to fluid shifts from paracentesis on the day 
prior to admission as well as low PO intake in the setting of 
AMS. Hypotension and ___ resolved with IV albumin. Hyperkalemia 
resolved with insulin and kayexalate.

# Hypotension: Patient presented with SBP in ___ and improved 
with albumin in the ED to ___. It was felt to be due to 
fluid shifts from paracentesis on ___, as well as likely 
hypovolemia given AMS and decreased PO intake. No concern for 
bleeding or sepsis with baseline CBC and lack of fever. She 
continued to received IV albumin during her hospital course, 
with which her SBP improved to ___ and patient remained 
asymptomatic.  

# Hyperkalemia: Patient presented with K 6.7 with EKG changes. 
Given low Na, likely the result of low effective arterial volume 
leading to poor K excretion, with likely exacerbation from ___. 
AM cortisol was normal. K improved with insulin and kayexalate 
and K was 5.2 on day of discharge. Bactrim was held during 
hospital course. 

# ___: Patient presented with Cr 0.7 from baseline Cr is 
0.3-0.4. It was felt to be likely due to volume shift from her 
paracentesis on the day prior to admission as well as now low 
effective arterial volume, likely ___ poor PO intake ___ AMS. Cr 
improved to 0.4 with albumin administration. Furosemide and 
Bactrim were held during hospital course.   

#GOC: The ___ son (HCP) met with Dr. ___ 
outpatient hepatologist) during ___ hospital course. They 
discussed that the patient is not a transplant candidate 
givenevere underlying lung disease (FEV1 ~0.8), hypoxia, RV 
dilation and very low BMI. A more conservative approach was 
recommended and the patient was transitioned to DNR/DNI. The 
patient agreed with this plan. She was treated with the goal of 
treating any any correctable issues. Social work met with the 
patient prior to discharge. The patient was interested in 
following up with palliative care, for which an outpatient 
referral was made. 
 
# Altered Mental Status: Patient presented with confusion that 
was most likely secondary to hepatic encephalopathy. Based on 
outpatient records, patient has had steady decline in 
decompensated cirrhosis and mental status. No signs of infection 
and head CT was negative as well. Mental status improved with 
lactulose in the ED and patient reports that she has not been 
taking lactulose regularly at home. Patient was also continued 
on rifaximin.   

# HCV Cirrhosis: Genotype 3a. Patient is decompensated with 
increasing ascites and worsening hepatic encephalopathy. She is 
dependent on twice weekly paracentesis. Spironolactone was 
recently stopped due to hyperkalemia. Patient is not a 
transplant candidate given her comorbidities COPD per outpatient 
hepatologist. The patient would like to continue biweekly 
paracenteses as an outpatient.

# HIV: Most recent CD4 count 173 on ___. HIV viral load on 
___ was undetectable. She was continued on her home regimen 
of raltegravir, emtricitabine, and tenofovir. Bactrim 
prophylaxis was held during admission because of hyperkalemia.   


# COPD: Patient on 3L NC at home. She was continued on her home 
regimen.

TRANSITIONAL ISSUES:
-Follow up with Palliative Care as outpatient
-Bactrim prophylaxis (HIV+) was held during hospital course due 
to ___. Consider restarting as outpatient.
-Furosemide was held due to ___, consider restarting as 
outpatient
-Follow up with hepatology
-Continue biweekly therapeurtic paracenteses
-Code status: DNR/DNI
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO TID 
2. Tiotropium Bromide 1 CAP IH DAILY 
3. Raltegravir 400 mg PO BID 
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
5. Furosemide 40 mg PO DAILY 
6. TraMADOL (Ultram) 50 mg PO Q8H:PRN Pain 
7. Fluticasone Propionate 110mcg 1 PUFF IH BID 
8. Calcium Carbonate 500 mg PO BID 
9. Rifaximin 550 mg PO BID 
10. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 
Wheezing 
11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY 

 
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID 
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
3. Fluticasone Propionate 110mcg 1 PUFF IH BID 
4. Lactulose 30 mL PO TID 
5. Raltegravir 400 mg PO BID 
6. Rifaximin 550 mg PO BID 
7. TraMADOL (Ultram) ___ mg PO Q6H:PRN pain 
8. albuterol sulfate 90 mcg/actuation inhalation Q6H:PRN 
Wheezing 
9. Tiotropium Bromide 1 CAP IH DAILY 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
Hypotension
Hyperkalemia
Acute Kidney Injury

Secondary:
HIV
Cirrhosis
COPD
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
 
Discharge Instructions:
Dear Ms. ___,

You were admitted to ___ because of confusion, low blood 
pressure, and a high potassium value. Your confusion improved 
with lactulose. Your blood pressure improved with extra fluids 
and your potassium improved as well. You also had small degree 
of kidney injury when you came to the hospital, and this also 
improved with fluids. While you were here, you discussed 
changing your goals of care to focusing on symptom management 
and treatment of reversible processes, such as an infection. 
While you were in the hospital, you were seen by one of our 
social workers. You will also follow up with Palliative Care in 
their clinic and will continue to have therapeutic paracenteses.

It has been a pleasure taking care of you and we wish you all 
the best,
Your ___ Care team
 
Followup Instructions:
___

{'altered mental status': ['Chronic hepatitis C with hepatic coma'], 'hypotension': ['Other iatrogenic hypotension'], 'hyperkalemia': ['Hyperpotassemia'], 'hepatic encephalopathy': ['Chronic hepatitis C with hepatic coma'], 'ascites': ['Other ascites'], 'COPD': ['Chronic airway obstruction, not elsewhere classified'], 'HIV': ['Asymptomatic human immunodeficiency virus [HIV] infection status'], 'cirrhosis': ['Cirrhosis of liver without mention of alcohol']}