Cirrhosis of liver without mention of alcohol Congenital factor VIII disorder Human immunodeficiency virus [HIV] disease Chronic hepatitis C without mention of hepatic coma Anomalous atrioventricular excitation Other esophagitis
 
Name:  ___                     Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Penicillins
 
Attending: ___.
 
Chief Complaint:
liver biopsy
 
Major Surgical or Invasive Procedure:
Liver biopsy ___

 
History of Present Illness:
___ yo M w/ hemophilia, factor VIII deficiency, hep C/cirrhosis 
with coinfection with HIV secondary to contaminated factor VIII 
in ___, admitted for observation post liver biopsy for hepatic 
mass workup. Had rising AFP (61 on ___ --> 181 on ___ 
and found to have a right lobe lesion on MRI (but not on 
ultrasound or CT). Lesion is 2.8-cm x 2.0-cm within segment 
IVb/V of liver, with irregular almost septal-like enhancement. 

Of note, cirrhosis decompensated by variceal UGIB. His last CD4 
count was 236, 31%, HIV VL undetectable. Recently seen Dr. ___ 
on ___ and his HAART was changed from ritonavir/atazanavir to 
raltegravir 400mg BID. He was also continued on truvada 1mg po 
daily.   

On arrival to the floor, patient feels well and has no 
complaints. States that the biopsy went well without any 
complications. 

ROS: per HPI, denies fever, chills, night sweats, headache, 
vision changes, rhinorrhea, congestion, sore throat, cough, 
shortness of breath, chest pain, abdominal pain, nausea, 
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, 
dysuria, hematuria.
  
 
Past Medical History:
1. Hemophilia A - mild, transfusion only during procedures
2. HIV- Dx ___ contracted from clotting factor
3. HCV- Dx ___ G-4 infection. h/o pegIFN/RBV treatment x 3 
months and withdrawn due to non-response.
4. WPW tachycardia - diagnosed in the late ___ and does not 
cause him any discomfort  
5. Cirrhosis. Path report, ___: Grade 2 necroinflammatory  
    
changes; Stage 4 fibrosis c/w cirrhosis. 
6. PCP pna in the early ___  
7. s/p cholecystectomy

 
Social History:
___
Family History:
His brother died at ___ of complications of hemophilia in ___. 
No other family history of lymphoma or malignancies. Father had 
triple bypass. 
 
Physical Exam:
ADMISSION PHYSICAL EXAM
VS:  98.2, 115/74, 80, 20, 97% RA
GENERAL: Well appearing M who appears stated age. Comfortable, 
appropriate and in good humor.  
HEENT: Sclera anicteric. PERRL, EOMI, OP clear  
NECK: Supple with low JVP  
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, 
rubs or gallops. No S3 or S4 appreciated.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use, moving air well and 
symmetrically. CTAB, no crackles, wheezes or rhonchi.  
ABDOMEN: Distended but Soft, non-tender to palpation. well 
healed RUQ scar from a previous cholecystectomy, biopsy site 
covered with dressing and c/d/i, no sign of hematoma and no 
tenderness to palpation. +splenomegaly. No shifting dullness or 
fluid wave.    
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No 
edema. 
SKIN: discoloration most notable at lower b/l shins and forehead 
(pt states it is secondary to HAART) 

DISCHARGE PHYSICAL EXAM
VS:  98.5, 120/78, 67, 18, 98% RA
GENERAL: Well appearing M who appears stated age. Comfortable, 
appropriate and in good humor.  
HEENT: Sclera anicteric. PERRL, EOMI, OP clear  
NECK: Supple with low JVP  
CARDIAC: RRR, S1 S2 clear and of good quality without murmurs, 
rubs or gallops. No S3 or S4 appreciated.  
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp 
were unlabored, no accessory muscle use, moving air well and 
symmetrically. CTAB, no crackles, wheezes or rhonchi.  
ABDOMEN: Distended but Soft, non-tender to palpation. well 
healed RUQ scar from a previous cholecystectomy, biopsy site 
covered with bandaid and c/d/i, no sign of hematoma and no 
tenderness to palpation. +splenomegaly. No shifting dullness or 
fluid wave.    
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. No 
edema. 
SKIN: light discoloration most notable at lower shins, forehead 
(pt states it is secondary to HAART) 
 
Pertinent Results:
ADMISSION LABS
___ 05:15PM BLOOD WBC-2.7* RBC-3.22* Hgb-13.4* Hct-38.6* 
MCV-120*# MCH-41.6* MCHC-34.7 RDW-14.8 Plt Ct-57*
___ 05:15PM BLOOD ___ PTT-60.7* ___
___ 05:15PM BLOOD Glucose-116* UreaN-13 Creat-0.5 Na-136 
K-3.3 Cl-105 HCO3-23 AnGap-11
___ 05:15PM BLOOD ALT-72* AST-121* AlkPhos-74 TotBili-2.3*
___ 05:15PM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8

DISCHARGE LABS
___ 05:42AM BLOOD WBC-2.7* RBC-3.12* Hgb-13.0* Hct-37.2* 
MCV-119* MCH-41.7* MCHC-34.9 RDW-13.8 Plt Ct-53*
___ 05:42AM BLOOD ___ PTT-60.6* ___
___ 05:42AM BLOOD Glucose-101* UreaN-12 Creat-0.5 Na-135 
K-3.8 Cl-105 HCO3-25 AnGap-9
___ 05:42AM BLOOD ALT-68* AST-114* LD(LDH)-229 AlkPhos-73 
TotBili-1.9*

RELEVANT LABS
___ 08:30AM BLOOD FacVIII-77
___ 05:42AM BLOOD FacVIII-45*

___ CT FLUOROSCOPY-GUIDED CORE BIOPSY
IMPRESSION:
CT fluoroscopy-guided core biopsy of a contour deforming 
isoattenuating lesion within segment IV.  Pathology pending.

___ LIVER BIOPSY (PATHOLOGY)
Liver lesion, segment IVb/V, targeted needle core biopsy:
 
1.  No malignancy identified.
 
2.  Established cirrhosis (Stage 4 fibrosis, confirmed by 
trichrome and reticulin stains).
 
3.  Scattered bile duct hamartomas; see note.
 
4.  Mild to moderate portal/septal, mild periportal and lobular, 
predominantly mononuclear inflammation with scattered apoptotic 
hepatocytes (Grade 2).
 
5.  No significant steatosis or iron deposition identified (iron 
stain evaluated).
 
 
Note:  The features are those of established cirrhosis, 
clinically secondary to chronic viral hepatitis C, with Grade 2 
inflammation. No malignancy is identified; recommend 
radiographic correlation to ensure sampling of the reported mass 
lesion. Given the presence of scattered bile duct hamartomas, an 
underlying component of polyfibrocystic liver disease cannot be 
excluded.

___ CYTOLOGY
NEGATIVE FOR MALIGNANT CELLS.
 
Brief Hospital Course:
___ yo M with history of hemophilia/factor VIII deficiency, hep 
C/cirrhosis with coinfection with HIV secondary to contaminated 
clotting factor, decompensated by prior UGIB admitted for 
observation after liver biopsy for hepatic mass workup.  

# Hemophilia s/p liver biopsy: No complications from biopsy. 
Received factor VIII prior to procedure and post procedure. No 
signs of bleeding or discomfort at the biopsy site. Denied 
abdominal pain, fevers/chills, sob. Hct remained stable. Factor 
VIII was checked day after biopsy and it was 45. Per hematology 
recommendations, he will continue with Advate ___ generation 
recombinant factor VIII) 1500 q12h for five more days (day 1: 
___. 

# HCV Cirrhosis: decompensated by varices and UGIB. Currently 
stable on nadolol. MELD score is 10. No evidence of HE or 
ascites. Inactive on the liver transplant list at the present 
time because his MELD score has been around 10 or less. New 
found liver lesion on MRI 2.8-cm x 2.0-cm within segment IVb/V 
of liver with recent rising AFP (61 on ___ --> 181 on 
___. Per pathology report, no sign of malignancy, 
cirrhosis secondary to viral hepC with grade 2 inflammation. In 
addition, presence of scattered bile duct hamartomas, which may 
indicate underlying component of polyfibrocystic liver disease.  


# HIV: stable, followed by Dr. ___. Currently on HAART and 
doing well. History of opportunistic infection with PCP 
pneumonia in the ___. Last CD4 on ___ was 236, viral load < 
20/ml. He was continued on his home dose of Truvada 
(emtricitabine-tenovir) 200/300 mg qd, Raltegravir 400 mg bid 
(integrase inhibitor), Zidovudine 300 mg bid (NRTI), and 
prophylaxis with bactrim SS 400/80 qd. 

# Esophagitis: continued on home omeprazole 20 mg qd

# TRANSITIONAL ISSUES
-liver biopsy pathology results without signs of malignancy; 
presence of scattered bile duct hamartomas
-patient to complete 5 days of Advate q12h
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
2. Nadolol 40 mg PO DAILY 
3. Omeprazole 20 mg PO DAILY 
4. Raltegravir 400 mg PO BID 
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 
6. Sumatriptan Succinate 25 mg PO DAILY:PRN headache 
at the onset of headache. can be repeated after two hours if no 
relief 
7. Zidovudine 300 mg PO BID 
8. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 
2. Multivitamins 1 TAB PO DAILY 
3. Nadolol 40 mg PO DAILY 
4. Omeprazole 20 mg PO DAILY 
5. Raltegravir 400 mg PO BID 
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 
7. Zidovudine 300 mg PO BID 
8. Sumatriptan Succinate 25 mg PO DAILY:PRN headache 
at the onset of headache. can be repeated after two hours if no 
relief 
9. ADVATE *NF* (antihemoph.FVIII plas-alb free) 1,500 (+/-) unit 
Injection q12 Duration: 5 Days 

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary diagnosis:
  - hemophilia
  - cirrhosis
Secondary diagnosis:
  - HIV
  - Hepatitis C

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

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure taking care of you during your stay at ___ 
___. You were admitted to the 
hospital after a liver biopsy for monitoring given your history 
of hemophilia.  You were treated with factor VIII repletion, and 
tolerated the procedure well.  You will need to continue to 
administer the factor VIII as prescribed.  

After you go home, please schedule an appointment with Dr. ___ 
___ followup regarding the biopsy results. 
 
Followup Instructions:
___

{'hemophilia': ['Congenital factor VIII disorder'], 'factor VIII deficiency': ['Congenital factor VIII disorder'], 'hep C/cirrhosis': ['Cirrhosis of liver without mention of alcohol', 'Chronic hepatitis C without mention of hepatic coma'], 'coinfection with HIV': ['Human immunodeficiency virus [HIV] disease'], 'variceal UGIB': ['Cirrhosis of liver without mention of alcohol'], 'rising AFP': ['Cirrhosis of liver without mention of alcohol'], 'right lobe lesion on MRI': ['Cirrhosis of liver without mention of alcohol'], 'irregular almost septal-like enhancement': ['Cirrhosis of liver without mention of alcohol'], 'splenomegaly': ['Cirrhosis of liver without mention of alcohol'], 'WPW tachycardia': ['Anomalous atrioventricular excitation'], 'PCp pna': ['Other esophagitis']}