Portal hypertension Other ascites Cirrhosis of liver without mention of alcohol Unspecified viral hepatitis C without hepatic coma Chronic airway obstruction not elsewhere classified Bipolar disorder unspecified Posttraumatic stress disorder Personal history of tobacco use
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
Worsening ABD distension and pain 
 
Major Surgical or Invasive Procedure:
Paracentesis

 
History of Present Illness:
___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, 
bioplar, PTSD, presented from OSH ED with worsening abd 
distension over past week.  
Pt reports self-discontinuing lasix and spirnolactone ___ weeks 
ago, because she feels like "they don't do anything" and that 
she "doesn't want to put more chemicals in her." She does not 
follow Na-restricted diets. In the past week, she notes that she 
has been having worsening abd distension and discomfort. She 
denies ___ edema, or SOB, or orthopnea. She denies f/c/n/v, d/c, 
dysuria. She had food poisoning a week ago from eating stale 
cake (n/v 20 min after food ingestion), which resolved the same 
day. She denies other recent illness or sick contacts. She notes 
that she has been noticing gum bleeding while brushing her teeth 
in recent weeks. she denies easy bruising, melena, BRBPR, 
hemetesis, hemoptysis, or hematuria.  
Because of her abd pain, she went to OSH ED and was transferred 
to ___ for further care. Per ED report, pt has brief period of 
confusion - she did not recall the ultrasound or bloodwork at 
osh. She denies recent drug use or alcohol use. She denies 
feeling confused, but reports that she is forgetful at times.  
In the ED, initial vitals were 98.4 70 106/63 16 97%RA  
Labs notable for ALT/AST/AP ___ ___: ___, 
Tbili1.6, WBC 5K, platelet 77, INR 1.6  

 
Past Medical History:
1. HCV Cirrhosis  
2. No history of abnormal Pap smears.  
3. She had calcification in her breast, which was removed  
previously and per patient not, it was benign.  
4. For HIV disease, she is being followed by Dr. ___ Dr.  
___.  
5. COPD  
6. Past history of smoking.  
7. She also had a skin lesion, which was biopsied and showed  
skin cancer per patient report and is scheduled for a complete  
removal of the skin lesion in ___ of this year.  
8. She also had another lesion in her forehead with purple  
discoloration. It was biopsied to exclude the possibility of  
___'s sarcoma, the results is pending.  
9. A 15 mm hypoechoic lesion on her ultrasound on ___  
and is being monitored by an MRI.  
10. History of dysplasia of anus in ___.  
11. Bipolar affective disorder, currently manic, mild, and PTSD. 
 
12. History of cocaine and heroin use.  

 
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.  
Her last alcohol consumption was one drink two months ago. No  
regular alcohol consumption. Last drug use ___ years ago. She  
quit smoking a couple of years ago.  

 
Physical Exam:
VS: 98.1 107/61 78 18 97RA  
General: in NAD  
HEENT: CTAB, anicteric sclera, OP clear  
Neck: supple, no LAD  
CV: RRR,S1S2, no m/r/g  
Lungs: CTAb, prolonged expiratory phase, no w/r/r  
Abdomen: distended, mild diffuse tenderness, +flank dullness, 
cannot percuss liver/spleen edge ___ distension  
GU: no foley  
Ext: wwp, no c/e/e, + clubbing  
Neuro: AAO3, converse normally, able to recall 3 times after 5 
minutes, CN II-XII intact  

Discharge:

PHYSICAL EXAMINATION:  
VS: 98 105/70 95
General: in NAD  
HEENT: anicteric sclera, OP clear  
Neck: supple, no LAD  
CV: RRR,S1S2, no m/r/g  
Lungs: CTAb, prolonged expiratory phase, no w/r/r  
Abdomen: distended but improved, TTP in RUQ, 
GU: no foley  
Ext: wwp, no c/e/e, + clubbing  
Neuro: AAO3,  CN II-XII intact  

 
Pertinent Results:
___ 10:25PM   GLUCOSE-109* UREA N-25* CREAT-0.3* SODIUM-138 
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9
___ 10:25PM   estGFR-Using this
___ 10:25PM   ALT(SGPT)-100* AST(SGOT)-114* ALK PHOS-114* 
TOT BILI-1.6*
___ 10:25PM   LIPASE-77*
___ 10:25PM   ALBUMIN-3.3*
___ 10:25PM   WBC-5.0# RBC-4.29 HGB-14.3 HCT-42.6 MCV-99* 
MCH-33.3* MCHC-33.5 RDW-15.7*
___ 10:25PM   NEUTS-70.3* LYMPHS-16.5* MONOS-8.1 EOS-4.2* 
BASOS-0.8
___ 10:25PM   PLT COUNT-71*
___ 10:25PM   ___ PTT-30.9 ___
___ 10:25PM   ___
.

CXR: No acute cardiopulmonary process.  
U/S:  
1. Nodular appearance of the liver compatible with cirrhosis. 
Signs of portal  
hypertension including small amount of ascites and splenomegaly. 
 
2. Cholelithiasis.  
3. Patent portal veins with normal hepatopetal flow.  
Diagnostic para attempted in the ED, unsuccessful.  
On the floor, pt c/o abd distension and discomfort.
 
Brief Hospital Course:
___ HCV cirrhosis c/b ascites, hiv on ART, h/o IVDU, COPD, 
bioplar, PTSD, presented from OSH ED with worsening abd 
distension over past week and confusion.  

# Ascites - p/w worsening abd distension and discomfort for last 
week. likely ___ portal HTN given underlying liver disease, 
though no ascitic fluid available on night of admission. No 
signs of heart failure noted on exam. This was ___ to med 
non-compliance and lack of diet restriction. SBP negative
diuretics:  
> Furosemide 40 mg PO DAILY  
> Spironolactone 50 mg PO DAILY, chosen over the usual 100mg 
dose d/t K+ of 4.5.   
 CXR was wnl, UA negative, Urine culture blood culture negative. 
 
Pt was losing excess fluid appropriately with stable lytes on 
the above regimen. Pt was scheduled with current PCP for 
___ check upon discharge.   
Pt was scheduled for new PCP with Dr. ___ at ___ and 
follow up in Liver clinic to schedule outpatient screening EGD 
and ___.   
 

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY 
2. Spironolactone 50 mg PO DAILY 
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 
4. Raltegravir 400 mg PO BID 
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
6. Nicotine Patch 14 mg TD DAILY 
7. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 

 
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing, SOB 
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
3. Furosemide 40 mg PO DAILY 
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet 
Refills:*3
4. Ipratropium Bromide Neb 1 NEB IH Q6H SOB 
5. Nicotine Patch 14 mg TD DAILY 
6. Raltegravir 400 mg PO BID 
7. Spironolactone 50 mg PO DAILY 
8. Acetaminophen 500 mg PO Q6H:PRN pain 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Ascites from Portal HTN

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you! You came to us with 
stomach pain and worsening distension. While you were here we 
did a paracentesis to remove 1.5L of fluid from your belly. We 
also placed you on you 40 mg of Lasix and 50 mg of Aldactone to 
help you urinate the excess fluid still in your belly. As we 
discussed, everyone has a different dose of lasix required to 
make them urinate and it's likely that you weren't taking a high 
enough dose. Please take these medications daily to keep excess 
fluid off and eat a low salt diet. You will follow up with Dr. 
___ in liver clinic and from there have your colonoscopy 
and EGD scheduled. Of course, we are always here if you need us. 
We wish you all the best!
Your ___ Team.  
 
Followup Instructions:
___

{'worsening abd distension': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'abd pain': ['Portal hypertension', 'Other ascites', 'Cirrhosis of liver without mention of alcohol'], 'gum bleeding': ['Unspecified viral hepatitis C without hepatic coma'], 'forgetfulness': ['Bipolar disorder', 'unspecified', 'Posttraumatic stress disorder']}