Acute pancreatitis Alcohol withdrawal Other secondary thrombocytopenia Cirrhosis of liver without mention of alcohol Disorders of magnesium metabolism Hypocalcemia Nausea with vomiting Posttraumatic stress disorder Other psoriasis Schizoaffective disorder unspecified Unspecified essential hypertension Personal history of other infectious and parasitic diseases Other and unspecified hyperlipidemia Obesity unspecified Gout unspecified Depressive disorder not elsewhere classified Asymptomatic human immunodeficiency virus [HIV] infection status Hypopotassemia Esophageal reflux Diarrhea Alcohol abuse unspecified Body Mass Index 32.0-32.9 adult
 
Name:  ___.              Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins / Abacavir / baclofen
 
Attending: ___.
 
Chief Complaint:
Abdominal Pain
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ HIV cirrhosis alcoholism who presents after being
discharged from ___ earlier today. He was requesting detox. Soon
after discharge, he states that he went home and drank small
amount of liquor and believes that he has some pancreatitis. He
comes in complaining of epigastric pain that started immediately
after consuming alcohol. Some Nausea with emesis. ___ pain. He
does not report f/c, chest pain shortness of breath prior or
constipation, or diarrhea, weight loss, neuro sx, cough, sudden
blindness, rhinorrhea, sore throat, dysuria, 
He had been sober for ___ years up until ___ but then had flash
backs from his PSTD. He then relapsed drinking. His last drink
was midnight ___.
.
In ER: 
VS:   00:51 8 97.1 100 130/98 18 98% RA 
.
Meds Given: 
Ondansetron 4 mg 
1000 mL NS  
 Morphine Sulfate 2 mg 
Potassium Chloride 40 mEq 
Morphine Sulfate 2 mg 
Potassium Chloride 40 meq 
Potassium Chloride 40 mEq 
Fluids given: 1L NS
Radiology Studies: none
Consults called: none
________________________________________________________________
ROS:
SKIN:           [] All Normal
[+ ] Rash- psoriasis controlled        [ ] Pruritus
Headache
HEME/LYMPH:    [X] All Normal
[ ] Easy bruising   [ ] Easy bleeding    [ ] Adenopathy

PSYCH:         [] All Normal
[+ ] Mood change- depressed - in the process of changing
therapist, his old therapist left and he could not get a 
referral
until ___.        [-]Suicidal/Homicidal Ideation  [ ] Other: 


ALLERGY:
[ +]Medication allergies: PCN - hives, abacavir -> flu like sx.  

[ ] Seasonal allergies

[X]all other systems negative except as noted above 
 
Past Medical History:
- HIV 
- ? Schizoaffective disorder
- Alcoholism 
- Psoriasis 
- Hypertension
- Hepatitis B, resolved per patient report
- Peyronie's disease
- Hyperlipidemia
- Obesity
- Gout
- LSIL in anal PAP
- ___ cyst   

 
Social History:
___
Family History:
Mother died of pancreatic cancer at age ___. Father died of old 
age at ___. He was diagnosed with prostate cancer ___ years 
earlier.

 
Physical Exam:
1. VS: T = 98.7 P = 92 BP = 130/78 RR = 20 O2Sat on  _92% on RA 
GENERAL:  Elderly male who looks older than his stated age. 
Nourishment:OK  
Grooming:OK  
Mentation: alert, speaks in full sentences.  
2. Eyes: [X] WNL 
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[X] Moist  [] Endentulous  [] Ulcers  [] Erythema  [] JVD ____ 
cm
[] Dry  [X] Poor dentition  [] Thrush  [] Swelling  [] Exudate
4. Cardiovascular [] WNL
[X] Regular  [] Tachy  [X] S1 [X] S2 [+] Systolic Murmur     
___,
Location: LUSB
[X] Edema RLE  None 
[X] Edema LLE None 
2+ DPP b/l
[X] Vascular access  [X] Peripheral [] Central site:
5. Respiratory [X]WNL
[X] CTA bilaterally  [ ] Rales  [ ] Diminshed
[X] Comfortable     [ ] Rhonchi   [ ] Dullness

6. Gastrointestinal [ X] WNL - NABS
[X] Soft  [] Rebound [] No hepatomegaly  [] Non-tender
[+]epigastric tendernes [] No splenomegaly
[] Non distended  [] distended  [+] bowel sounds Yes  [] guiac:
positive/negative

7. Musculoskeletal-Extremities [X] WNL
[ ] Tone WNL  [X]Upper extremity strength ___ and symmetrical  [
]Other:
[ ] Bulk WNL    [X] Lower extremity strength ___ and symmetrica 
[
] Other:
[X] Normal gait  []No cyanosis  [ ] No clubbing  [] No joint
swelling
8. Neurological [X] WNL
[X] Alert and Oriented x 3 [ ] Romberg: Positive/Negative  [ ] 
CN
II-XII intact  [ ] Normal attention  [ ] FNF/HTS WNL [] 
Sensation
WNL  [ ] Delirious/confused  [ ] Asterixis Present/Absent  [ ]
Position sense WNL
[ ] Demented  [ ] No pronator drift  [] Fluent speech
9. Integument  [X] WNL
[X] Warm  [X] Dry  [] Cyanotic [] Rash: 
I didn't appreciate any psoriatic lesions
10. Psychiatric [X] WNL
[x] Appropriate [] Flat affect [] Anxious [] Manic [] 
Intoxicated
[] Pleasant [] Depressed [] Agitated [] Psychotic 
 
Pertinent Results:
Admission Labs:
___ 01:30AM BLOOD WBC-10.9 RBC-3.88* Hgb-13.5* Hct-37.5* 
MCV-97 MCH-34.7* MCHC-35.9* RDW-14.6 Plt ___
___ 01:30AM BLOOD ___ PTT-23.3* ___
___ 01:30AM BLOOD Glucose-233* UreaN-20 Creat-1.1 Na-140 
K-2.5* Cl-102 HCO3-16* AnGap-25*
___ 01:30AM BLOOD ALT-37 AST-56* AlkPhos-108 TotBili-0.3
___ 01:30AM BLOOD Albumin-4.0 Calcium-8.0* Phos-1.5*# 
Mg-1.0*
___ 08:00AM BLOOD pH-7.47* Comment-GREEN TOP
___ 08:00AM BLOOD freeCa-0.94*

Discharge Labs:
___ 07:37AM BLOOD WBC-6.1 RBC-3.72* Hgb-13.2* Hct-37.4* 
MCV-101* MCH-35.6* MCHC-35.4* RDW-16.0* Plt Ct-83*
___ 07:37AM BLOOD Glucose-109* UreaN-10 Creat-0.9 Na-141 
K-4.1 Cl-105 HCO3-22 AnGap-18
___ 09:05AM BLOOD ALT-26 AST-39 AlkPhos-93 TotBili-1.1
___ 07:37AM BLOOD Calcium-8.5 Phos-3.5 Mg-1.4*

RUQ Ultrasound:
FINDINGS: 
 
LIVER: The liver is diffusely echogenic. The contour of the 
liver is smooth.
There is no focal liver mass. Main portal vein is patent with 
hepatopetal
flow. There is no ascites.
 
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD 
measures 5 mm.
 
GALLBLADDER: There is no evidence of stones or gallbladder wall 
thickening.
 
PANCREAS: The pancreas is not well evaluated due to overlying 
bowel gas.
 
SPLEEN: Normal echogenicity, measuring 11.2 cm.
 
KIDNEYS: The right kidney measures 11.2 cm. The left kidney 
measures 10.7 cm.
Normal cortical echogenicity and corticomedullary 
differentiation is seen
bilaterally. There is no evidence of masses, stones or 
hydronephrosis in the
kidneys.
 
RETROPERITONEUM: Visualized portions of aorta and IVC are within 
normal
limits.
 
IMPRESSION: 
 
Echogenic liver consistent with steatosis. Other forms of liver 
disease and
more advanced liver disease including steatohepatitis or 
significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
 
 
Brief Hospital Course:
___ year old male with h/o HIV absolute CD4 = 571, HIV viral load 
undetectable, ETOH who presents with acute pancreatitis, EtOH 
withdrawal.

ACUTE PANCREATITIS: Lipase elevated to 500 on admission. Unclear 
if he truly had pancreatitis. His presentation was mild as 
abdominal exam was benign throughout and never tender to 
palpation. He was initially on bowel rest and then advanced to 
regular diet.

ETOH with withdrawal: Treated for withdrawal on CIWA and scored 
for approximately 36 hours requiring valium. Symptoms improved 
over the course of hospitalization. Social work consulted and 
discussed a plan for treatment as an outpatient. 

Thrombocytopenia: Drop in platelets on admission. Prior values 
as low as ~100. This was likely due to a combination of alcohol 
toxicity, bone marrow suppression and under production of 
thrombopoeitin from liver disease. Possible sequestration as 
well. No signs of overt cirrhosis on RUQ. Smear without 
schistocytes. His platelets had a nadir of 65 and on day of 
discharge were increased to 81. 

Hypomag/hypoK/hypocalcemia: He had severe depletion of calcium, 
magnesium and potassium. This was repeleted aggressively 
throughout his admission. 

GOUT: Podagra of the right great toe developed. History of this 
in the past, treated with colchicine.

Diarrhea: Ruled out C diff and this improved during his 
admission. 

Chronic issues:
HTN: continued atenolol.
HIV:well controlled, continued HAART
PSORIASIS: Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 
GERD: Pantoprazole 40 mg PO Q24H 
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 75 mg PO DAILY 
2. Acamprosate 333 mg PO TID 
3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 
4. Multivitamins 1 TAB PO DAILY 
5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral 
QHS 
6. Pantoprazole 40 mg PO Q24H 

 
Discharge Medications:
1. Acamprosate 333 mg PO TID 
2. Atenolol 75 mg PO DAILY 
3. Clobetasol Propionate 0.05% Soln 1 Appl TP DAILY 
4. Multivitamins 1 TAB PO DAILY 
5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral 
QHS 
6. Pantoprazole 40 mg PO Q24H 
7. FoLIC Acid 1 mg PO DAILY 
8. Thiamine 100 mg PO DAILY 
9. OxycoDONE (Immediate Release)  5 mg PO Q4H:PRN pain 
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours 
Disp #*5 Tablet Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Alcohol withdrawal
pancreatitis
thrombocytopenia 
schizoaffective
HIV

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

 
Discharge Instructions:
Mr. ___, you were admitted to ___ with abdominal pain and 
alcohol withdrawal. Due to the alcohol abuse you had low 
calcium, magnesium, and potassium which were all treated 
aggressively.

You were treated for alcohol withdrawal and you met with our 
social worker to develop a plan for you to help quit alcohol 
use. 
 
Followup Instructions:
___

{'Abdominal Pain': ['Acute pancreatitis'], 'Nausea with emesis': ['Acute pancreatitis'], 'Epigastric tenderness': ['Acute pancreatitis'], 'Mood change- depressed': ['Depressive disorder, not elsewhere classified'], 'Rash- psoriasis controlled': ['Other psoriasis'], 'Headache': [], 'Pruritus': [], 'Easy bruising': [], 'Easy bleeding': [], 'Adenopathy': [], 'Mood change- in the process of changing therapist': [], 'Suicidal/Homicidal Ideation': [], 'Other:': ['Schizoaffective disorder, unspecified', 'Hypopotassemia', 'Esophageal reflux', 'Diarrhea', 'Alcohol abuse, unspecified', 'Body Mass Index 32.0-32.9, adult']}