tokens: Admission Date : 2015-03-26 Discharge Date : 2015-03-30 Date of Birth : 1967-03-08 Sex : F Service : MEDICINE Allergies : Morphine / Histamine H2 Inhibitors / Heparin Agents Attending : Terry T Trott , M.D. Chief Complaint : Increasing abdominal girth Major Surgical or Invasive Procedure : 4u FFP Paracentesis History of Present Illness : 47 female with h/o HCV cirrhosis compocated by encephalopathy , ascites , and h/o portal vein thrombosis ( right anterior portal vein ) and portalcaval shunt ( reversed flow in main portal vein ) presents from liver clinic with increasing abdominal girth . She also described sob , nausea , worsening lower ext edema . She denied abd pain , fevers , chills . She was admitted for a large volume paracentesis but her INR on admission was 3.8 . She received 4units of FFP which decreased her INR to 2.2 and then 2 more units during the tap . She then had 6L of non-bloody ascitic fluid removed without complication . She received 36gm of albumin following the tap . Her BP on admission was 120/70 and remained stable following the tap . Over the next several hours , pt complained of abd pain but this resolved on its own without medication . In the am , she was found to have a hct of 24 , down from 32 and plts 35 , down from 72 . She received 2 units of plts and 1 unit of PRBC s. Her BP was then noted to be decreased at 80/40 which improved mildly to 90/30 with 1.5L of NS . Temp noted to be low at 94 and she was placed on bear hugger which improved temp to 96.7 . Her mental status also had decreased from admission and her urine output was minimal , 225cc over the past 12 hours . Creatinine this am was 1.9 from 0.9 yesterday . Previous hospital course ( per H&P ): She was recently hospitalised from 02-23 / 03-04 for abdominal discomfort at which time she underwent paracentesis that ruled out SBP and relieved her abdominal pain . She also underwent US that revealed patent portal and hepatic vessels . While her discharge summary maintains that she was continued on Furosemide / Spirinolactone / Propranolol , the patient did not receive any scripts on discharge and as a result did not take these medications . Also , due to worsening renal function , she was started on octreotide / midodrine / albumin for hepatorenal syndrome ( Cr 3.3 at its worst ) which resolved prior to her discharge . The hospitalisation was also significant for mild DIC for which she received cryoglobulins and UTI (+ Enterococcus and + Klebsiella ). She received a 7 day course of amoxicillin for which Enterococcus was sensitive but Klebsiella unknown . Past Medical History : HCV cirrhosis c/b esophageal varices , ascites , partial portal vein thrombosis h/o gastritis morbid obesity recent cholecystitis 08-10 h/o EtOH abuse sickle cell trait Social History : Patient denies etoh and tobacco use . She has a history of heavy alcohol use . Lives alone second floor apartment ; son and mother nearby Family History : None Physical Exam : Physical Exam : T 95 , BP 120/70 , HR 82 , RR 20 , 96% RA Wt 301.6 lb HEENT : + scleral icterus . No thrush . Neck : No Donna , normal thyroid contour Lungs : CTAB Cardiac : RRR , no murmurs Abdomen : obese , soft , mildly distended dull to percussion throughout , no tenderness , liver non-palpable due to large volume of ascited Extremities : 05-09 + pretibial edema extending above knee R > L , no asterixis . No palmar erythema Pertinent Results : 2015-03-26 10:10 AM BLOOD WBC - 8.1 RBC - 3.69 * Hgb - 11.0 * Hct - 32.4 * MCV - 88 MCH - 29.8 MCHC - 33.9 RDW - 26.0 * Plt Ct - 72 *# 2015-03-26 10:10 AM BLOOD Neuts - 68.3 Bands - 0 Lymphs - 19.8 Monos - 10.6 Eos - 1.1 Baso - 0.2 2015-03-26 10:10 AM BLOOD Hypochr - 1 + Anisocy - 2 + Poiklo - 2 + Macrocy - 2 + Microcy - NORMAL Polychr - NORMAL Ovalocy - OCCASIONAL Target - OCCASIONAL Schisto - OCCASIONAL Tear Dr Clark 2015-03-26 10:10 AM BLOOD PT - 23.0 * PTT - 63.2 * INR(PT) - 3.8 2015-03-26 10:10 AM BLOOD Glucose - 76 UreaN - 17 Creat - 0.8 Na - 129 * K - 3.9 Cl - 101 HCO3 - 19 * AnGap - 13 2015-03-26 10:10 AM BLOOD ALT - 33 AST - 65 * AlkPhos - 70 TotBili - 30.3 * DirBili - 20.8 * IndBili - 9.5 2015-03-26 10:10 AM BLOOD Albumin - 3.1 * 2015-03-26 10:10 AM BLOOD Ammonia - 39 RADIOLOGY 1. Small cirrhotic liver with what appears to be a portocaval shunt . 2. Moderate ascites . 3. Cholelithiasis without evidence of acute cholecystitis . 4. No hydronephrosis . 5. Borderline splenomegaly . Brief Hospital Course : A/P : 48 yo morbidly obese woman with HCV cirrhosis c/b encephalopathy , esophageal varices and partial vein thrombosis ( but no hx of SBP ) presents with increasing abdominal girth likely secondary to ascites . Admitted for diagnostic / therapeutic paracentesis and then transferred to the ICU for hypotension , confusion and anemia . # Liver cirrhosis : MELD score of 34 on admission . Pt became more encephalopathic during her hospital course . She was not a transplant candidate due to her obesity . A family meeting was held on hospital day #4 which included the pt 's closest family members , her hepatologist , Dr. Steidl , her PCP , Dr. Popoff and the ICU team . After it was explained that the pt 's prognosis was very poor given that she was not a transplant candidate , the decision was made by the family and the medical team to withdraw care . The pt was made comfortable and she expired several hours later . # Recurrent ascites : On the medical floor , pt had a large volume paracentesis ( 6 liters ) followed by replacement with albumin . She had no evidence of SBP . # Hypotension : Pt became hypotensive following the large volume paracentesis despite replacement with albumin . This was thought to be 04-09 the large volume tap verses sepsis though she had no other evidence of sepsis . She was placed on pressors to maintain a MAP > 55 . Once the decision was made to withdraw care , the pressors were discontinued . # Anemia : Hct dropped following the tap and there was concern for bleed into her abdomen . She received one unit of PRBC s. CT of the abdomen and pelvis showed no evidence of bleed . Her hematocrit remained stable at 24-26 following the acute drop. # ARF : Creatinine has increased from 0.9 on admission to 1.9 on admission to ICU . Urine lytes with Na of 10 indicating either pre-renal or hepatorenal . Fluid challenge with 36gm of albumin , one unit of PRBCs and 2L of NS . Will check creatinine this afternoon . Pt previously diagnosed with hepatorenal and was started on midodrine , octreotide and albumin ; these were continued . Her creatinine continued to increase , likely due to her worsening liver failure . Pt expired during this admission after family discussion to make her comfort care only . Medications on Admission : Rifaximine 200 mg tid Lactulose 30 cc qid titrated to 3-4 BM / day Protonix 40 mg po qd Discharge Medications : none Discharge Disposition : Home Discharge Diagnosis : none Discharge Condition : expired Discharge Instructions : none Followup Instructions : none Tracy Doris MD 79-274 Completed by : Melvin Thomas MD 50-805 2015-06-22 @ 1413 Signed electronically by : DR. Micheal J. Rozzi on : MON 2015-07-20 1:53 PM ( End of Report )