August 17, 2013
Patient: Betty Boop
Married status: Widowed
No. of children: 2
Date admitted: 09/03/13
Admitting diagnosis: Hematemesis, melanotic stools, cirrhosis, hepatorenal syndrome.
Signs and symptoms on admission: fatigue, lethargic, oriented x 1, vomiting bright red blood, reported recent black stools, jaundice.
Summary of History and Physical on admission: Patient has a history of hepatitis C, alcohol abuse, cirrhosis, GI bleed, and pancreatitis. Patient was lethargic, with mental status changes. Patient’s appearance is jaundice, stomach distended and ...view middle of the document...
Patient was found to have electrolyte abnormalities low Na, K, acidosis, anemia and coagulopathy. She was transfused 4 units of RBC and 4 FFP, with vitamin K. Potassium improved from 2.6 to 3.3. The EGD showed several varices gastropathy and portal hypertension. Comfort care is being discussed since she is in end stage liver failure. Doctors also state she is not a candidate for liver transplant given the fact that she was still abusing alcohol prior to admission.
Patient is a 79 year old white female, widowed with two children. She was found to have collapsed while checking the mail and talking to her neighbor. She has told her friend/ neighbor that she has been vomiting for two days but thought she had the flu. Patient has a history of Cirrhosis, hepatitis C, and alcohol abuse. Patient’s vitals taken at 8:30am T-37.3C, P-87, R-27, and B/P-113/67. Patient appears to be jaundice, and her abdomen is distended and hard upon palpation. According to pain grading scale from 1-10, 10 being the most intense, my patient stated she is at a pain level of 10/10. Patient is A & O X 2, to person and place. She falls asleep easily. Patient’s skin is dry with poor turgor. She also has a stage 1 decubiti’s ulcer. The physician was notified. Her Foley catheter appears to be clean of any crust or discharge. Patient did not state any pain when cleaning peritoneal area. There is decreased output. There was only approximately 50cc of urine in bag. The color of urine was dark brown, physician was notified, and fluids were restricted per physician order. There is also edema present on lower extremities bilaterally. Will monitor her weight daily. Her femoral central catheter is working well. The site appears clean with no signs of redness and patient does not complain of any pain when palpating site. Encouraged patient to call for help when trying to get out of bed since she does not look stable on her own. Will continue to monitor electrolytes and replace as ordered.
Lab and Diagnostic Test Results: n/a
A CBC is performed because it provides information about the hematologic system and many other organ systems. This patient has been having hematemesis and black stools, causing her hemoglobin and hematocrit levels to decrease. With a complete CBC it is possible to identify what the patients H and H is. Her hemoglobin and hematocrit are low because of hematemesis and black stools. The coagulation test is used to evaluate bleeding disorders. Blood clotting tests are used to diagnose and assess bleeding problems and to monitor people who take warfarin or other anticoagulant medicines. Clot reaction is prolonged in thrombocytopenia or abnormal platelet function. The time required to form a clot and for edges of the clot to retract from the sides of the glass tube is the clot reaction time. Her clot reaction time was prolonged. Chronic diseases, such as cirrhosis may cause the concentration of certain electrolytes in the...