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Morning Report SBP.pptx - Morning Report History of...

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Morning ReportTempHRRRBPO2%98.11223860/3087% on RAHistory of Presenting IllnessA 62-year-old male with past medical history of Alcoholic cirrhosisportal hypertension, hx of variceal bleed presented withabdominal pain.Review of Systems(+) shortness of breath, nausea, vomiting, weakness(-) fever, constipation, diarrhea.Past MedicalHistoryAlcohol CirrhosisDVTIVC filterHx of bacteremiaClostridium difficile colitisHx of head trauma andconcussionPortal hypertensionFamily HistoryFather- Lung cancerMedicationsFurosemide 20mg dailyMidodrine 10mg TIDSpironolactone 25mgLactuloseVitaminsSocial HistoryStopped smoking 10 yrs agoStopped drinking 10 years agoDenied IVDULives at home.ExamGen: A&Ox3, Obese, jaundiceEye: sclera icterusCVS: RRR, no M/G/R. no JVPRESP: diminished air entry on right side. NowheezesGI: tender to palpation, distended. Distended visibleveinsNeuro: No deficitsExtremities; +2 pittingedema. No erythema orvisible woundINR: 3.6PT: 37.9APTT: 41WBC: 17.6Hg: 7.9Hct: 22.9Plt: 189Na: 127K: 4.6Cl: 90Glucose 81Bicarb 22BUN 30Cr: 2.8albumin: 3.2ALT: 41AST: 81Bili total: 10.4Bili direct: 5.7Bili indirect: 4.7Lactate: 5.4Ammonia 73
Hospital Course-Patient received Albumin and IV fluid-Received broad spectrum Antibiotics-No improvement in Blood pressure-Started on Levophed- Paracentesis and CXR-Increasing requirement for Norepinephrine required vasopressin andhydrocortisone-Started on Octreotide and Albumin
ParacentesisColorYellowAppearanceHazyWBC738RBC<3000Segments57Lymph24
Hepatic hydrothorax

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Term
Fall
Professor
N/A
Tags
Ascites, Spontaneous bacterial peritonitis

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