| ELECTRONIC HEALTH RECORD |  |
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 Ava Williamson | Gender: Female | 70 yrs | DOB: 03/22/YEAR | Pref Lang: English |
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| Allergies: NKA | ||||
| Bed: 6136-01 | MRN: 324564 | CSN: 805426969 Attend Provider: P. M. Myers | Patient Class: Inpatient | Readmission: N |
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| P. M. Myers, MD Physician Hospitalist |
H&P Date of Service: MONTH/DAY/YEAR HR:MIN Signed Creation Time: MONTH/DAY/YEAR HR:MIN |
NCPro Hospital Daily Progress Note
Day 3 Time 12:46 pm
Code Status: Full
Discharge Disposition: Patient expected to be discharged tomorrow.
Overview:
Ava presented to the Emergency Department three days ago with slight itching, dark urine, pale fatty stools, swollen ankles, abdominal pain, nausea and a feeling of exhaustion. She had noticed her symptoms worsening over the course of several weeks but avoided seeking medical attention. She decided to reduce her alcohol consumption two days prior to admission believing she would recover if she cut back.
Ava was admitted to the Acute Care ward.
Subjective:
Patient has bilateral LE edema, fatigue, 14 point ROS otherwise negative
Objective:
Vitals: 118/62, HR 101, RR 14, RA sat 98%
Temp: 37oC (98.7oF) (o)
Estimated body mass index is 26.57 kg/m² as calculated from the following:
Height as of this encounter: 157.5 cm (5' 2")
Weight as of this encounter: 71.89 kg (158.5 lb)
Measured BMI: 29 kg/m2
Input/Output Summary:
Intake/Output Summary (Last 24 hours)
| Gross per 24 hour | |
| Intake | 785 ml |
| Output | 710 ml |
| Net | -75 ml |
Physical Exam
Constitutional: She is oriented to person, place, and time and well-developed, well-nourished, and in mild distress.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: External ear normal.
Left Ear: External ear normal.
Nose: Nose normal.
Mouth/Throat: Oropharynx is clear and moist. No oropharyngeal exudate.
Eyes: Conjunctivae and EOM are normal. Pupils are equal, round, and reactive to light. Right eye exhibits no discharge. Left eye exhibits no discharge. No scleral icterus.
Neck: Normal range of motion. Neck supple. No JVD present. No tracheal deviation present. No thyromegaly present.
Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Exam reveals no gallop and no friction rub.
No murmur heard.
Pulmonary/Chest: Effort normal and breath sounds decreased throughout. No respiratory distress. She has no wheezes. She has no rales. She exhibits no tenderness.
Abdominal: Soft. Bowel sounds are normal. She exhibits distension, positive fluid wave, no palpable masses, no splenomegaly noted. Mild abdominal tenderness throughout
Musculoskeletal: Normal range of motion. She exhibits 2+ edema, no tenderness or deformity.
Lymphadenopathy: She has no cervical adenopathy.
Neurological: She is alert and oriented to person, place, and time. She has normal reflexes. No cranial nerve deficit. She exhibits normal muscle tone. Gait normal. Coordination normal. GCS score is 15. No asterixus
Skin: Skin is warm and dry. No rash noted. She is not diaphoretic. No erythema. No pallor. No jaundice
Psychiatric: Affect and judgment normal.
Nurses notes and vitals reviewed.
Assessment and Plan:
Cirrhosis
Liver failure
Transaminitis
Ascitis
Day 1
The patient has undergone a therapeutic tap, thus far gram stain is positive for GN organisms, cultures still pending, fever is improving. Will continue rocephin 1 gm IV pending culture results, await GI consult. Repeat liver panel daily.
Await blood culture, check PT/PTT
Add Lasix 20 mg daily, spironolactone 50 mg daily.
Avoid Tylenol in the setting of liver disease.
Will give albumin 25 g every 6 hours X 2 days
Add nadolol
Hold narcotics
Day 2
Paracentesis cultures have returned positive with E Coli, blood cultures negative after 24 hours. now afebrile. more hemodynamically stable. GI following. For now continue albumin every 6 hours for another 24 hours, repeat liver panel today slightly improved
Continue lasix, aldactone, nadolol
Patient is not a transplant candidate due to recent ETOH use
Day 3
Will change IV antibiotics to po levaquin, blood cultures are negative X 48 hours. D/C albumin, her edema is mildly improved, liver panel improving daily. Continue lasix, aldactone, nadolol.
Tenatively plan discharge home tomorrow if stable.
Hyponatremia
Day 1
Likely secondary to liver disease, will send urine electrolytres, osmo. Fluid restrict 1 liter total per day, avoid free water, prefer po tomato juice, fluids with solutes.
She did receive one dose of Lasix in the ED which should improve the hyponatremia
Day 2
hyponatremia workup c/w liver disease with urine sodium < 20, urine osmo 205.
Continue po fluid restriction and diuretics as above serial BMP
Day 3
Serum sodium is 133 today
Hypokalemia
Day 1
Serum potassium low in the setting of reduced po intake, was supplemented, now 4.0 this am, will continue to check daily
Day 2
Resolved
Day 3
Resolved
Anemia of Chronic Disease
Day 1
Stool for OB X 3
Will transfuse 1 unit of blood now and repeat as needed prn hgb < 7
Day 2
Repeat hgb 7.8, continue to monitor. Stool for OB were negative X 2 so far
Day 3
Hgb stable, 7.7, continue to monitor
Hypertriglyceridemia
Secondary to liver disease, will monitor
Protein Calorie Malnutrition
Day 1
Have asked dietitian for consult
Day 2
Dietitian recommendations noted, continue high protein diet
ETOH Withdrawal
Day 1
Continue CIWA protocol, her score today is zero, valium prn
Start vitamin supplements (Thiamine, Folate and MVI)
Day 2
CIWA score zero, continue to monitor
Day 3
CIWA score remains zero.
No need for valium. Have asked the SW to d/w patient cessation of ETOH use, treatment facilities in area
VTE prophylaxis
Sequential compression devices while in bed
Medications
Lasix 20 mg daily oral
Spironolactone 50 mg daily oral
MVI 1 tab daily oral
Cefotaxime 2 g every 8 hours IV
Albumin 25 g every 6 hours IV X 48 hours
Nadolol 20 mg daily
Active Inpatient Problems
Cirrhosis
Liver failure
Transaminitis
Hyponatremia
Hypokalemia
Anemia of Chronic Disease
Hypertriglyceridemia
Fever
Protein Calorie Malnutrition
Ascites
ETOH Withdrawal
Contact
Daughter Beth Williams at 333-333-3333