Background Information
Patient: Betty Boop
Sex: Female
Married status: Widowed
Age: 79
No. of children: 2
Occupation: Disabled
Date admitted: 09/03/13
Admitting diagnosis: Hematemesis, melanotic stools, cirrhosis, hepatorenal syndrome.
Allergies: Codeine
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 tender to palpation.
History of Surgical Procedures with dates: Not Known
Patient was brought to Memorial ER by her neighbor who was with patient when she collapsed while checking the mail. She has multiple home medications including lactulose. She has a history of hepatitis C, pancreatitis, cirrhosis, and alcohol abuse. Patient is allergic to codeine. She is suspected to have hepatic portal hypertension. She is on Protonix, multi-vitamins, folic acid, thiamine and lactulose at home. Skin appears to be jaundice. Seems confused and is only oriented to place. Pupil’s dilated, not reactive to light and conjunctivae pallor. Patient is in no respiratory distress. Her abdomen is hard and tender. Blood Pressure 79/46, pulse of 59, respiratory rate of 22, and temp of . Patient possibly has a GI bleed and an NG tube will be inserted to observe the amounts of blood and monitor if she is actively bleeding. A central line was placed and an EGD was performed to rule out any active bleeding as well as esophageal varices. Patient was transferred from to CCU on 8/4/2013. Her diagnosis is hepatorenal syndrome. She currently is not bleeding and her NG tube has been discontinued.
