tokens: Admission Date : 2014-03-31 Discharge Date : 2014-04-09 Date of Birth : 1964-04-26 Sex : M Service : Liver Transplant Surgery Service ADMISSION DIAGNOSIS : Hepatitis C cirrhosis . HISTORY OF PRESENT ILLNESS : The patient is a 49 year-old man with hepatitis C cirrhosis complicated by encephalopathy , positive esophageal varices , now with worsening confusion and lethargy . The patient has been admitted 5 x in the past to Nantucket Cottage Hospital since 11-30 for encephalopathy . Most recently admitted on 2014-03-19 to 2014-03-22 . Infectious work-up was negative . Trazodone stopped . Patient was started on Lactulose and Rifaximine which improved his mental status . Today , on 2014-03-03 , the patient was seen in clinic with increased lethargy , confusion . Wife reports that the patient has a history of lethargy and confusion , similar to the symptoms for which the patient was recently admitted . The patient also reports that he has had " yellowish eyes , some shaking and his breath smelled more like ammonia over the past 3 days ." The patient has been compliant with his medications . He has had one bowel movement today which is on 2014-03-31 . He has had night sweats for the past 2 weeks . He denies any abdominal pain . He gets cold easily but denies fevers . His stools have been brown to green . PAST MEDICAL HISTORY : HCV cirrhosis . Underwent treatment with Interferon 10 years ago . He stopped secondary to aggressive behavior . History of hepatic encephalopathy . Esophageal varices . EGD on 2013-12-08 demonstrated 5 cores of varices , grade 1 to 2 at the lower third of the esophagus . Four bands were placed without difficulty . Also , the patient has a past medical history of hypertension , glucose intolerance , peripheral neuropathy . The patient was taken off of Neurontin because it started to worsen his mental status . MEDICATIONS ON ADMISSION : Nadolol 20 mg q. Day . Protonix 20 mg q. 24 hours . Osamine 200 mg t.i.d. Lactulose 30 mg q.i.d. Lasix 40 mg q. Day . Insulin regular . Amlodipine 5 mg q. Day . Retazepine 50 mg q h.s. Testosterone 4 mg q. 24 hours . ALLERGIES : No known drug allergies . SOCIAL HISTORY : The patient is married and lives with his wife . Previously employed as a security guard at a nuclear power plant . Quit tobacco 20 years ago and currently denies any cigarette . Alcohol : No alcohol use . The patient contracted HCV 20 years ago secondary to IV drug use . FAMILY HISTORY : Father died of metastatic colon cancer . Mother died of end stage renal disease . PHYSICAL EXAMINATION : Vital signs were stable . Weight was 122.5 . General : Patient is in no acute distress . Lethargic , occasionally falling asleep . HEENT : Pupils equal , round and reactive to light . Sclera mildly icteric . Neck : No LAD . Lungs clear to auscultation bilaterally . CV : Regular rate and rhythm . Normal S1 and S2 without murmurs or rubs . Positive gynecomastia . Abdomen : Positive bowel sounds , soft , nondistended , nontender . Obvious ascites . 1+ edema bilaterally . Neurologic : Awake , alert and oriented x3 . Cranial nerves 2 through 12 intact . There was mild asterixis . HOSPITAL COURSE : The patient was admitted . Patient continued on Lactulose . The goal was 3 to 4 stools per day . Continue on Rifaximine . Continue Lasix . Physical therapy was consulted on 2014-04-01 . On 2014-04-02 , the patient was awake , alert and oriented , taking Lactulose . Difficulty with word finding at times . Denies any pain or discomfort . Abdomen : Slightly distended , nontender . Positive bowel sounds . Positive flatus . Good op site . Ultrasound was performed on 2014-04-01 demonstrating severe portal hypertension with massive peri splenic varices and splenorenal shunt . Portal vein was fully patent . Repeat hepato fungal flare . On 2014-04-04 , the transplant service was consulted because the patient was possibly going to the operating room for transplant on 2014-04-04 . The patient did go to operating room on 2014-04-04 and the patient had cadaveric liver transplant performed by Dr. Michael Sanders . Please see detailed operative note for more information about the procedure . Postoperatively , the patient was transferred to the ICU . The patient received MMF 1 gram b.i.d. , Flagyl 500 mg IV x1 . The patient also received Unasyn for 2 days , Fluconazole , heparin , Protonix , insulin , morphine , Bactrim . The patient was on Propofol for 2 days . LABORATORY DATA : On 2014-04-04 , labs were as follows : WBC of 8.3 ; hematocrit of 30.6 ; platelets 69 ; sodium 132 ; 3.9 , 102 , 22 , serum creatinine of 13 and 1.1 . Glucose 114 . AST 87 . ALT 44 . Alkaline phosphatase 169 . PT of 20.6 . PTT of 38.7 . INR of 2.0 . On postoperative day number 1 , duplex ultrasound of the patient 's liver was performed demonstrating normal appearing portal veins and hepatic arteries . There was normal flow within the middle hepatic vein . There appears to be a decreased and sluggish flow within the right and left hepatic veins with loss of normal respiratory variations , wave forms and the intrahepatic portion . Additionally , there is diminished color flow with confluence of the hepatic veins . These findings may reflect thrombus within the left and right hepatic veins . Caval narrowing is seen , most likely correlation to clinical history is recommended and further evaluation of the CT or short-term ultrasounds for follow-up was recommended . The Feeney Gann-Burlington drain on postoperative day number demonstrated medial output of 780 with lateral output of 150 . Patient went to the floor and patient was on the floor on 2014-04-07 . Patient continued getting Acyclovir , Prednisone , MMF one gram b.i.d . The patient was on FK 2 and 2 that was started on postoperative day number 2 . Diet was advanced . Patient was ambulating . Waltham-Ludlow drains put out on the 13th 620 and 380 . Physical therapy was re consulted . Omalley was consulted on 2014-04-08 for better glucose control since the patient was on steroids . Social work was consulted . Patient continued to do very well , ambulating , following the diet . Patient was transfused 1 unit of platelets on 2014-04-08 for platelet count of 66 . A heparin independent antibody was sent off on 2014-04-07 which was unremarkable . On 2014-04-09 , patient continued to do very well , ambulating , tolerating a diet , urinating without difficulty . Drains continued to put out significant amount of fluid . Patient 's labs from 2014-04-10 were the following : 7.1 , hematocrit of 30.8 , platelets 90 . Sodium of 138 ; potassium 3.5 ; 106 , 28 , 31 , 1.0 , glucose 134 . AST 82 . ALT 176 . Alkaline phosphatase 78 which all have significantly decreased since postoperative day number 1 . Total bilirubin was 0.9 . On 2014-04-09 , FK level was 10.3 . Patient left on 2014-04-09 with VNA to home . DISCHARGE MEDICATIONS : Protonix 40 mg q. 24 . Moltipine 5 mg q. Day . Fluconazole 400 mg q. 24 hours . Prednisone 20 mg q. Day . MMF 1000 mg b.i.d. . Lopressor 50 m b.i.d. Percocet 1 to 2 tabs q. 4 to 6 hours prn . Colace 100 mg b.i.d. Bactrim SS 1 tab q. Day . Tacrolimus 3 mg b.i.d. Lasix 20 mg b.i.d. Valcyte 900 mg q. Day . Patient is on insulin sliding scale with fixed dose . FOLLOW UP : The patient is to follow-up with Dr. Amanda Pepper on the following dates : 2014-04-14 at 9 a.m. , 2014-04-24 at 10:20 a.m. and 2014-05-01 at 10:20 a.m. If the patient can not make those appointments or has any questions about the appointments , please call 787-984-9608 . The patient is to call 787-984-9608 if any fevers , chills , nausea and vomiting , abdominal pain , inability to take medications , inability to eat or drink . Patient needs to have labs every Monday and Thursday including a CBC , chem-10 , AST , ALT , alkaline phosphatase , albumin , total bilirubin and Prograf level need to be obtained . Please fax results to ( 728 ) 250-3265 . All cultures have been unremarkable . Cultures were obtained on 2014-03-31 . Urine culture and blood culture have been unremarkable on 2014-04-03 . Hepatitis viral load was 76,500 . Pathology demonstrates that the pathology results of the liver were not finalized . Darrell Diiorio , MD , PHD 02-366 Dictated By : Deborah JP Allen , M.D. MEDQUIST36 D : 2014-04-11 14:30:39 T : 2014-04-11 15:05:40 Job #: 88167 Signed electronically by : DR. Greg Jones on : FRI 2014-04-25 2:37 PM ( End of Report )