DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Ascites.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male admitted secondary to increasing abdominal girth. He is presently status post paracentesis. Per the patient, we were asked to see him because it all came back overnight, and according to him, it usually takes a couple of months. The patient was just seen in consultation a couple of months ago for his ascites secondary to his chronic liver disease. The patient has a history of cirrhosis and ascites due to alcoholism with frequent paracenteses approximately every three months. According to the patient, there is also a questionable history of hepatitis C, but it has not been documented. Acute hepatitis panel in January, A, B core, B surface, and C were all nonreactive. The patient, as an outpatient, was supposed to be on spironolactone 25 mg b.i.d. and Lasix 20 mg once daily and noted that his bottles were empty at the time of consultation. He states he never followed up with the physician secondary to financial issues. According to the patient, he has no other complaints at this time. No dyspepsia, dysphagia, odynophagia, nausea, vomiting, melena or hematochezia.
PAST MEDICAL HISTORY: History of liver disease with cirrhosis and ascites secondary to ETOH with moderate to severe hepatocellular disease documented on nuclear medicine scan, coagulopathy secondary to liver disease, history of microcytic anemia with a history of transfusions.
PAST SURGICAL HISTORY: Denies.
SOCIAL HISTORY: He denies any tobacco use or alcohol intake. States he is not drinking.
FAMILY HISTORY: Not applicable.
ALLERGIES: None.
MEDICATIONS: Lasix 40 mg once daily and spironolactone 25 mg b.i.d.
REVIEW OF SYSTEMS: A 12-point review of systems completed and incorporated in history and physical, otherwise unremarkable.
PHYSICAL EXAMINATION:
VITAL SIGNS: He is 5 feet 8 inches, 155 pounds on admission. No current weight since then. Blood pressure 118/86, pulse 86, respirations 22. The patient is afebrile.
GENERAL: Alert and oriented. Ambulating in room without difficulty.
SKIN: Warm and dry and pink.
CHEST: Clear and bilaterally expanding. Respirations are even and unlabored.
CARDIOVASCULAR: S1 and S2. No rubs, murmurs or gallops. Rhythm is regular.
ABDOMEN: Large, distended with ascites. Bowel sounds are noted throughout. There is no guarding or rebound tenderness. Noted umbilical hernia. Area is nontender.
EXTREMITIES: The patient moving all extremities well and equal with no edema noted.
LABORATORY DATA: Reviewed. White count 3.7, hemoglobin 10.6, hematocrit 33.6, platelet count 172,000. This is slightly down from hemoglobin of 11.4 and hematocrit of 36.8 on admission. MCV 79.8, MCHC 31.8, RDW 15.6. Ammonia 16. Sodium 135, potassium 4.2, chloride 102, CO2 of 26, BUN 12, creatinine 0.9, and calcium 8.2. PT and INR elevated at 16.6 and 1.32.
IMPRESSION:
1. Moderate to severe hepatocellular disease documented by nuclear medicine with ascites, splenomegaly, coagulopathy with a history of ethanol abuse.
2. Splenomegaly.
3. Anemia, iron deficiency, which is stable.
4. Ascites, status post paracentesis with increasing abdominal girth since then.
5. Leukopenia and anemia secondary to hypersplenism.
RECOMMENDATIONS: At this time, to continue with supportive care. Strict I&O and daily weight. Fluid restriction of 1 liter a day. Medications have been adjusted, changed yesterday, with increasing Lasix to 40 mg once a day and increasing Aldactone to b.i.d. without any success. Today, increasing Lasix to b.i.d. and now we will increase Aldactone to 50 mg b.i.d. Further recommendations pending the patient’s status.
