DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Liver disease.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who has significant history of recent acute GI bleed. The patient was recently discharged from an outside hospital, where he underwent EGD and required seven bands for esophageal varices. Subsequently, the patient also received modified TIPS. According to family members, the patient returned to this hospital due to altered mental status, which started today. The patient was suggested to be on lactulose; however, he has uncontrolled diarrhea and he stopped two days ago. Presently, the patient denied abdominal pain, nausea, vomiting, fever, chills, blood in bowel movement. The patient had multiple workups previously for his liver disease with unknown cause. He did have a colonoscopy less than one year ago and had polyps.
PAST MEDICAL HISTORY: Acute promyelocytic leukemia, atrial fibrillation, portal hypertension, hyperlipidemia, and GERD.
PAST SURGICAL HISTORY: AICD, TIPS, left knee surgery, and cholecystectomy.
MEDICATIONS:
1. Zocor.
2. Betapace.
3. Finasteride.
4. Lactulose.
5. Omeprazole.
6. Digoxin.
7. Fish oil.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient denies family history of colorectal cancer or colon polyps or hereditary liver disease.
SOCIAL HISTORY: The patient denied alcohol, tobacco use.
REVIEW OF SYSTEMS: Fourteen systems reviewed, as stated in HPI.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake, confused. No acute distress.
VITAL SIGNS: Temperature 98.6 degrees, heart rate 68, respiratory rate 18, and blood pressure 150/88.
HEENT: EOMI, anicteric. Oral mucosa is moist.
NECK: No JVD. No bruits bilaterally. Supple.
HEART: Regular rhythm. No murmur, regurg, gallops. No S3, S4.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi, or crackles.
ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds. Negative for organomegaly.
EXTREMITIES: Positive for trace edema. Negative for Homans sign.
LABORATORY DATA: White blood count 6.6, hemoglobin 12.2, hematocrit 36.8, platelets 114, sodium 144. Potassium 3.8, chloride 110, CO2 is 20, BUN 14, creatinine 0.8, glucose 112, alkaline phosphatase 62, AST 28, ALT 46, total bilirubin 2.2, ammonium level 42. PT 14.6, INR 1.14. Troponin level 0.1. Hemoccult negative.
IMPRESSION:
1. Altered mental status, possibly related to transjugular intrahepatic portosystemic shunt. Other etiologies are possible, including infection versus medication versus compliance to lactulose versus others.
2. Portal hypertension.
3. Esophageal varices with multiple band placement recently.
4. Possible end-stage liver disease of uncertain etiology.
5. Recent acute gastrointestinal bleed.
6. Thrombocytopenia secondary to portal hypertension.
RECOMMENDATIONS:
1. Continue lactulose to keep stools soft, two to three bowel movements per day.
2. Xifaxan 200 mg two tablets p.o. t.i.d.
3. Will obtain records from outside hospital to review.
4. The patient will need to have liver biopsy for a definitive cause if he has not had one done.
5. Avoid sedative pain medications if possible.
