Other injury into spleen without mention of open wound into cavity Other ascites Hyposmolality and/or hyponatremia Unspecified fall Other and unspecified alcohol dependence continuous Alcoholic cirrhosis of liver Other specified disorders of stomach and duodenum Chronic kidney disease unspecified
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
___
 
Attending: ___.
 
Chief Complaint:
Transfer with ? splenic laceration  

 
Major Surgical or Invasive Procedure:
Diagnostic paracentesis
Therapeutic paracentesis of 9 Liters of ascitic fluid

 
History of Present Illness:
Mrs. ___ is a ___ woman with alcoholic cirrhosis, 
continued alcohol abuse, intermittent acute renal failure who 
presented to an outside hospital after her sister found her on 
the ground after a fall.  

At the OSH, she underwent trauma evaluation, which demonstrated 
a ? splenic laceration, so she was transferred to ___.  

Upon arrival, she reports abdominal fullness and reports feelign 
cold, but she has no frank abdominal pain. She denies lower 
extermity edema, shortness of breath, orthopnea. She denies 
hematemesis, coffee ground emesis or hematochezia or melena.  
She reports that her right orbit is mildly painful, but this is 
improving.  

All other review of systems negative.  

Of note, there is some mention in the OSH records of low-grade 
temps, but it is not apparent that attempts at paracentesis were 
made.  
 
Past Medical History:
- EtOH cirrhosis complicated by recurrent ascites and hx of 
hepatic encephalopathy. Known portal gastropathy.  
- EtOH abuse/dependence. Denies a history of alcohol withdrawal. 
 
- Multiple epsisodes of ARF due to prerenal azotemia versus HRS 
type II  
- Anemia  
- s/p umbilical hernia repair on ___  
- Psoriasis  
 
Social History:
___
Family History:
Negative for family history of liver disease
 
Physical Exam:
Vitals: 98.8, 152/78, 73, 18, 95%RA  
General: Alert, oriented x3, NAD, R eye with surrounding 
echymossis, jaundiced,  
HEENT: NCAT, PERRL, EOMI, + scleral icterus, MM dry, no lesions 
noted in OP  
Neck: supple, no significant JVD or carotid bruits appreciated  
Pulmonary: Decreased BS at both bases, R>L  
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated  
Abdomen: Distended, positive fluid wave, shifting dullness  
Extremities: Trace bilateral edema, 2+ radial, DP pulses b/l  
Neurologic: Alert, oriented x 3. Able to relate history without 
difficulty.  
 
Pertinent Results:
___ 07:15AM   WBC-6.5 RBC-3.39* HGB-10.3* HCT-31.2* MCV-92# 
MCH-30.4 MCHC-33.1 RDW-19.7*
___ 07:15AM   ALBUMIN-3.2* CALCIUM-8.7 PHOSPHATE-3.4 
MAGNESIUM-1.1*
___ 07:15AM   ALT(SGPT)-25 AST(SGOT)-98* ALK PHOS-142* TOT 
BILI-4.6*
___ 07:15AM   GLUCOSE-77 UREA N-19 CREAT-1.8* SODIUM-136 
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16
___ 09:00AM   ___ PTT-53.0* ___
___ 10:10AM ASCITES  WBC-30* ___ POLYS-5* LYMPHS-54* 
___ MESOTHELI-2* MACROPHAG-39*
___ 10:10AM ASCITES  TOT PROT-2.6 GLUCOSE-97 LD(LDH)-67 
ALBUMIN-1.4

___ 12:35PM   HCT-31.2*
___ 10:05PM BLOOD Hct-30.2*
___ 07:10AM BLOOD Hct-31.9* 
___ 06:45AM BLOOD Hct-28.9* 

Imaging:
OSH:
CT abdomen: massive ascites, wedge-shaped density in the upper 
aspect of the spleen, splenic laceration cannot be excluded.  

CT head: soft tissue swelling adjacent to right orbit, no 
intracranial pathology.  

CT abd/pelvis ___ at ___:
IMPRESSION: 
1. Splenic laceration. Unable to evaluate for active 
extravasation due to 
lack of IV contrast. 
2. Cirrhotic liver with splenomegaly and large ascites. Amount 
of ascites 
has increased. 
3. Interval decrease in size of left rectus sheath hematoma, 
almost resolved. 
4. Distended gallbladder with appearance of adenomyomatosis at 
the fundus and possible small gallstone. 

 
Brief Hospital Course:
Ms ___ is a ___ year-old female with alcoholic cirrhosis who 
presented to an OSH s/p fall, found to have a splenic laceration 
and transferred here for further care.

# Splenic laceration: Upon arrival she was hemodynamically 
stable.  Radiology was unable to open the imaging on the OSH CD, 
so a non-contrast abdominal/pelvis CT was completed which showed 
a moderate-sized splenic laceration (although radiology was 
unable to tell if it was actively bleeding due to lack of 
contrast).  Her Hct was trended and remained stable in the low 
30' to high 20's.  Transplant surgery was consulted and 
recommended conservative management.  On discharge her Hct was 
28.9.

# Alcoholic Cirrhosis:  The patient has a history of ESLD with 
history of encephalopathy and HRS.  A diagnostic para was 
negative for SBP.  She had ascites on exam and her diuretics 
were initially held in anticipation of a large volume 
paracentesis.  She was given 50 gm albumin the day prior to 
discharge and the day of discharge had a large-volume 
paracentesis of 9 L of ascitic fluid and received an additional 
50 gm of albumin.  She will follow up with her hepatologist as 
an outpatient next week.  She was continued on nadolol, a PPI, 
lactulose, rifaximin, and bactrim (for SBP prophylaxis).

# Continued alcohol use:  She was monitored on a CIWA scale, 
however did not display symptoms of withdrawal.  She was 
continued on thiamine, folic acid, and a multivitamin.  She was 
strongly encouraged to stop drinking do to alcohol's negative 
effects on her health.

# Chronic kidney disease:  The patient recently had HRS and has 
chronic renal insufficiency.  Her creatinine on admission was 
1.8 (the lowest value recorded in OMR for her recently).  Her 
diuretics were held and she received albumin as described above 
and her Cr trended down to 1.3 the day of discharge.  She was 
asked to restart her diuretics the day after discharge.

# Code: She is full code.

 
Medications on Admission:
Folic acid 1 mg po daily
Thiamine 100 mg po daily
Multivitamin daily
Omeprazole 40 mg po daily
Nadolol 40 mg po daily
Lasix 20 mg po daily
Aldactone 25 mg po daily
Lactulose 15 mL twice daily, titrating to ___ bowel movements 
per day
Rifaximin 400 mg po tid
Bactrim DS 1 tab 5 times per week
 
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).  

2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
3. Multivitamins     Tablet, Chewable Sig: One (1) Tablet PO 
DAILY (Daily).  
4. Nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.  
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.  
6. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.  
7. Lactulose 10 gram/15 mL Solution Sig: Fifteen (15) ML PO BID 
(2 times a day): Titrate to ___ bowel movements per day.  
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a 
day).  
9. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) 
Tablet PO 5X/WEEK (___).  
10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) 
Capsule, Delayed Release(E.C.) PO once a day.  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
Splenic laceration

Secondary:
Alcoholic cirrhosis
Hyponatremia
Chronic kidney disease
Chronic anemia

 
Discharge Condition:
Mental Status: Patient was oriented to person and place, but was 
slightly confused about the date.  Otherwise she answered 
questions appropriately.  No asterixis.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were transferred to ___ due to concern for 
damage to your spleen.  You had fallen and been taken to another 
hospital where there was concern for bleeding from the spleen.  
You underwent an abdominal/pelvis CT here which showed the 
damage to the spleen.  Your blood counts were monitored and 
remained stable.  

You underwent a diagnostic paracentesis to check for infection 
in the fluid in your stomach.  There was no evidence of 
infection.  The liver doctors saw ___ and recommended draining 
fluid from your abdomen to improve your abdominal distenion so 
you underwent a therapeutic paracentesis the day of your 
discharge.

It is very important that you stop drinking alcohol to prevent 
further damage to your liver.

No changes were made to your medications.  Continue your 
medications as previously prescribed.
 
Followup Instructions:
___

{'abdominal fullness': ['Alcoholic cirrhosis of liver', 'Other ascites'], 'cold': [], 'right orbit mildly painful': [], 'lower extremity edema': ['Chronic kidney disease'], 'shortness of breath': [], 'orthopnea': [], 'hematemesis': [], 'coffee ground emesis': [], 'hematochezia': [], 'melena': [], 'anemia': ['Chronic anemia'], 'splenic laceration': ['Other injury into spleen without mention of open wound into cavity'], 'alcoholic cirrhosis': ['Alcoholic cirrhosis of liver'], 'portal gastropathy': ['Alcoholic cirrhosis of liver'], 'hepatic encephalopathy': ['Alcoholic cirrhosis of liver'], 'acute renal failure': ['Chronic kidney disease'], 'prerenal azotemia': ['Chronic kidney disease'], 'umbilical hernia repair': [], 'psoriasis': [], 'low-grade temps': [], 'ARF': ['Chronic kidney disease'], 'HRS type II': ['Chronic kidney disease'], 'scleral icterus': ['Alcoholic cirrhosis of liver'], 'jaundiced': ['Alcoholic cirrhosis of liver'], 'Decreased BS at both bases': [], 'R>L': [], 'Distended': ['Other ascites'], 'positive fluid wave': ['Other ascites'], 'shifting dullness': ['Other ascites'], 'Trace bilateral edema': ['Chronic kidney disease'], '2+ radial': ['Chronic kidney disease'], 'DP pulses b/l': ['Chronic kidney disease'], 'Alert, oriented x 3': [], 'Able to relate history without difficulty': [], 'Negative for family history of liver disease': []}