DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Liver cirrhosis.
Thank you very much for this consult.
HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old Hispanic male who is known to our service from previous admission, known to have history of alcoholic liver disease, history of hypertension, diabetes mellitus, anxiety, history of colon cancer status post resection. The patient was admitted secondary to slurred speech. He was found to have TIA and is being followed by a neurologist at this time, and clinically doing well with the symptoms resolved. Upon questioning the patient, he states he has not drunk anymore alcohol for the past few years. He did have two beers this past Friday, which he states he seldom drinks, only on special occasions. He denies having any ascites, any fluid retention, any abdominal pain, nausea, vomiting, melena or any hematochezia symptoms.
His white count is at 5.6, hemoglobin 13.2, hematocrit 38.4, and platelets of 112. His PT and INR are at 13.2 and 1. Total bilirubin is at 3.6, direct bilirubin at 1.7, alkaline phosphatase of 118, AST of 90, ALT of 79.
He underwent a right upper quadrant ultrasound on this admission, which is currently pending. His previous ultrasound revealed no tumors, no masses and a normal study was noted at that time. His previous alpha-fetoprotein was at 4.8. His previous hepatitis profile has also been negative.
We are being consulted regarding his liver cirrhosis, compensated, secondary to history of alcoholism.
His previous EGD revealed no varices. He had a hiatal hernia, hemorrhagic gastritis with no metaplasia and no H. pylori noted. He had prominent reactive gastropathy, hiatal hernia, and small bowel biopsies that were negative at that time. The patient denies ever having any ascites or any hematochezia.
PAST MEDICAL HISTORY: As above. Also with history of seizure disorder, history of colon cancer status post hemicolectomy, history of subdural hematoma with craniotomy, coronary artery disease, tobacco addiction, and history of alcohol abuse with alcoholic liver disease, compensated.
MEDICATIONS: Reviewed and noted.
SOCIAL HISTORY: He is a smoker. He has a history of alcohol abuse. He states he only socially drinks, on special occasions, about two beers and does not drink heavily anymore. He lives alone.
REVIEW OF SYSTEMS: See history of present illness. All other systems are negative.
PHYSICAL EXAMINATION: Temperature 98.6, pulse 72, respirations 16, and blood pressure 148/94. This is a pleasant Hispanic male who appears to be in no acute distress. He is alert, awake, and oriented x3. He is well built and well nourished. He has a regular rate and rhythm. Lungs are clear to auscultation. Abdomen: Liver and spleen not palpable, soft, nontender, and nondistended. No rebound and no guarding. Obese. Absent bowel sounds. Extremities revealed no cyanosis, clubbing, or edema. Rectal exam was deferred.
LABORATORY DATA: See history of present illness.
IMPRESSION:
1. Alcoholic liver cirrhosis, compensated.
2. History of colon carcinoma, status post hemicolectomy with no repeat colonoscopy thereafter.
3. Transient ischemic attack.
4. Multiple medical problems. Please see history of present illness.
PLAN:
1. At this time, we would recommend repeating an ultrasound of the right upper quadrant to rule out any masses. Repeat the alpha-fetoprotein marker. The patient states his last beer was on Friday. He had two beers. We have counseled the patient again on abstinence of alcohol and he agrees to comply. We would fluid restrict this patient to 1.2 liters for 24 hours and continue on a 2-gram sodium diet with low protein intake. His liver cirrhosis is compensated at this time with the last esophagogastroduodenoscopy revealing no varices and no evidence of any portal hypertension. Continue proton pump inhibitor for gastric cytoprotection.
2. Regarding his history of colon CA, we highly recommend a colonoscopy in this patient. The patient does not want a colonoscopy on this admission, and we have discussed with the patient delaying the procedure may delay further diagnosis. He has agreed to outpatient colonoscopy. Again, we have discussed the importance of the colonoscopy. His previous CEA level was at 3.6. We would repeat CEA level. From GI standpoint, if the patient is discharged, he will follow up in approximately two to three weeks, at which point he will need an outpatient colonoscopy.
Thank you very much for this consult.
