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Jimena Marino Nieto, MSIII

Universidad Central del Caribe-School of Medicine
Internal Medicine Clerkship
Patient: A.C.R
Age: 64 years
Sex: Male

Record Number: 419329

Admission Date: 4/27/2013
Discharge Date: 5/2/2013

Chief Complaint: Tengo la barriga muy hinchada.

History of Present Illness:
A 64-year-old male patient with chronic liver disease, chronic ethanolism
arrived to HURRA Emergency Department with abdominal distension
progressively worsening since last week. He states pain is 3/10 in intensity.
Pain is constant and burning. This is not the first time he experienced this
symptoms. He has shortness of breath and states fatigue. Abdomen is
globose, tender and soft. He does not took any pill to alleviate pain. Denies
fever, chills, nausea, vomits, diarrhea, discoloration or pigmentation of
skin/sclera, halithosis, change in concentration/sensorium, hand tremor or
dizziness.
Previous illnesses and Hospitalizations:
1.Decompensated chronic liver disease. ( 2001, 2005, 2009, 2013)
Previous Blood Transfusions:
1.No.
Childhood illness and Immunizations:
1. no childhood ilness
2. Immunizations not up to date
Adult illness:
1. Chronic liver disease
2. Ascites
3. Chronic ethanolism
4. Facial ( nose) melanoma resected by history
Medications:
1. Spironolactone 100mg

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2. Furosemide 40mg
3. Hidrochlorothiazide 28mg
4. Bisacodil 5mg 2 tabs at 9 pm
Habits:
1. Chronic ethanolism
2. Illicit drug use: denies
3. Somking: denies
4. No exercises regularly
Allergies and Drug reactions:
1.None
Prosthetic Devices:
1.None
Social Life:
The patient lives with his wife in a cement house located in Bayamon. He
was a former electricist. All of her 4 sons are alive and in good health.
He has chronic ethanolism for the past 20 year. He is complaint with
treatment of hypertension. He does not exercise regularly. Has never been
enrolled in the military forces and has not traveled outside Puerto Rico in the
last 15 years. He denies any contagious disease in her close relatives. He has
Catholics believes.
Family history
1. Mother: Alive at age 95; Natural death.
2. Father: Deceased at 96; Natural death.
3. Children: 4 sons. No known medical conditions
4. Siblings: 9. All healthy.
Review of Systems:

General: Patient looks distressed and in pain. Has shortness of breaths and
looks fatigue. Denies fever, vomits, weight change, diarrhea, change in bowel
habits, hematochezia or melena. Denies night sweats or excessive sweating.
Eyes: Denies visual changes, diplopia or blurred vision, eye pain or itching,
yellow sclera, watering eyes or other symptoms.
Ears: Denies hearing difficulty, earache, running ear, vertigo, and tinnitus.
Nose and throat: Denies epistaxis, congestion, sneezing spells, running nose,
enlarged tonsils, hoarseness, sore throat, or postnasal drip.

Breasts: Denies lumps, pain or tenderness, or nipple discharge.

Musculoskeletal: Currently has pain in her back and states that is radiating
to the front in the left side ( groin area). Denies shoulder pain, joint pain,
muscle weakness or muscle pain.
Respiratory: Denies cough or productive cough. Denies chest pain, hemoptysis, chest
cold, shortness of breath or wheezing. Previous PPD: Negative
Cardiovascular: Denies fainting or collapse, palpitations, chest pain or
discomfort, shortness of breath, paroxysmal nocturnal dyspnea, swelling of
ankles, claudication or orthopnea.
Gastrointestinal: Patient has nausea, but has not vomited. Nauseas started
after eating. Denies diarrhea. Denies dysphagia, heartburn, rectal bleeding,
abdominal pain, jaundice, rectal pain or acholia.
Genitourinary: Denies increased frequency, nocturia, incontinence, dribbling,
polyuria, discharge or vaginal discharge.
Gynecological: Grava 7 Para 5 Abortions 2. Patient experienced menarche at
12 years of age. Last menstrual period was 4/8/2013. She uses 1 pad per day.
Denies menorrhagia, metrorrhagia, or pelvic pain. Denies dyspaneuria.
Neurologic: Denies seizures, loss of consciousness, paralysis, tremor, changes
in handwriting, headaches, changes in speech, memory change, or trouble
with decision making.
Psychiatric: Denies crying spells, thoughts or attempts of suicide, social
withdrawal, hallucinations, delusions, anxiety or depression
Physical Exam:

Ethnicity: Hispanic/ Latino Height: 54 Weight: 150lbs BMI: 25.7

BP: 125/75 Temp: 36.0 Pulse: 95 RR: 22
General appearance: Patient is awake, alert and oriented to time, place, and
person. Patient visibly distress. Patient looks acutely ill. Patient has
shortness of breath and is fatigue.
Skin:
1. The skin is clear and no signs of jaundice, pallor, cyanosis, rashes,
petechiae, purpuras, or abnormal pigmentation are present.
Lymph nodes:
1. Submadibular and submental nodes are not enlarged and nontender.

Head:
1. Symmetric head, no masses, with normal texture and distribution of
dyed red hair.
Eyes:
1. Eyelids: no hemorrhages, no secretions, no redness
2. Sclera and conjunctiva: clear, no jaundice, injection or exudates
3. Pupils: Equal reactive to light and accommodation
4. Corneas: clear, no cloudiness, no cataracts noted
5. Extra ocular muscles: Extra ocular muscles intact
6. Fundi: Vessels emerge from nasal side of disc. Arteries are narrower
than veins. No tortuosity of vessels.
7. Snellen Chart: 20/20 vision reported
Ears:
1. External ears and canals: Clear with normal shape
2. Tympanic membranes: Clear pearly, with visible ossicles.
No bulges, perforations, or scarring visible.
3. Hearing: Grossly normal
4. Mastoid: No tenderness to touch or swelling
Nose:
1. Normal shape, no obstruction, no discharge, with normal nasal
septum, mucosa, and turbinates.
Mouth and Throat:
1. Lips: Rose color with no asymmetry, no sores
2. Gums and mucosa: Dry oral mucosa
3. Tongue: Moist, well palpated and protrudes in the midline, no atrophy
or deviation.
4. Teeth: No prosthesis, visible caries noted. 1 inferior molar absent on
the left.
5. Posterior pharynx: Clear, no erythema, exudates, injection, enlarged
tonsils or post nasal drip observed.
Neck:
1. Midline trachea, no JVD, no deformities, no masses.
2. No bruits, no tenderness, no enlarged nodes or abnormality of position.
3. Thyroid normal in size and contour
Thorax:
1. Poor respiratory effort. Respirations are shallow.
2. Normal shape and size, symmetric chest expansion, no retractions, no
spider angiomas or collateral circulation noted.
Lungs:
1. Respiratory distress and retractions. No expiratory grunting, stridor,
or hoarseness noted.
2. No dullness or hyperressonance
3. Clear bronchi-vesicular breath sounds present.
4. Crackles and rhonchi bilaterally

Breasts:
1. Mild gynecomastia
Heart:
1. No precordial asymmetry or hyperactivity and no JVD noted
2. No thrills or hyperactive impulse. Point of maximum impulse located
in normal position. All pulses palpable at +2.
3. Tachycardia, normal rhythm, no murmurs, rubs or gallops.
Abdomen:
1. Bowel sounds present in all quadrants.
2. Dullness to percussion.
3. No masses were palpated
4. Abdomen is severely globose and distended. Abdomen is not tender and
soft.
5. Liver is palpated 3 cm below costal margin.
Genitalia, Anus, and Rectum: Deferred
Musculoskeletal:
1. Normal alignment, mobility and no deformity of head and neck, spine,
ribs, pelvis; normal ROM and 5/5 strengths in all extremities. No
clubbing, edema.
Joints:
1. Normal range of motion, no heat, tenderness, swelling or redness.
Spine:
1. Low back pain.
2. Straight with normal thoracic and lumbar curves. Good posture, no
masses.
Neurological:
1. Mental Status Exam: Patient oriented in time, place, and person. No
depression, anxiety, or agitation. No hallucinations or delusions. No
suicidal or homicidal thoughts. Patient has intact recall, attention, and
concentration.
2. Normal mental status and development for age. Insight and judgment
were intact. Intact memory for both recent and remote events. No pain
on extension of neck, no feelings of sadness or guilt, no loss of energy,
no anxiety or agitation. Good coordination, no ataxia, no tremors. No
gross motor deficit. Deep Tendon Reflexes present and symmetrical.
Normal activity and no clonus. Negative Babinski. Cranial nerves
grossly intact ( CN I-XII).

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Assessment:
A 64-year-old male patient with chronic liver disease, chronic ethanolism
arrived to HURRA Emergency Department with abdominal distension
progressively worsening since last week. He states pain is 3/10 in intensity.
This is not the first time he experienced this symptoms. Abdoomen is globos
but nontender and soft. Patients symptomatology raises suspicion for an
acute episode of tensional ascites and decompensated chronic liver disease.
As a result patient will be started on IV antibiotics to cover for presumed
peritoneal infection. Diagnostic parasentecis will be performed. Patient will
be kept nothing per mouth to give bowel rest. 5;2 ratio of spironolactone;lasix
will be started to improve ascites. Albumin will be added to
pharmacotherpautical plan.
Differential diagnosis:
1. Congestive heart failure
ProCons2. Spontaneous bacterial peritonitis
ProCons3. Peritonitis.
ProConsPlan of Action:
Diagnostic:
1. Blood culture - 48 hour blood culture was negative
2. Urine culture -48 hour blood culture was negative
3. Urinalysis Unremarkable
4. EKG - Normal QRS complex. No acute ST changes. HR-89bpm
5. CBC: Hb= 10.3, Hct=31.0, PLT=117, WBC=6.72
6. BMP: Na=132, K=3.4, Cl=91, CO2= 27.5, BUN=9.3, Cr=0.8, Glucose=77
7. Paracentesis: diagnositc and therapeutic. r/o spontaneous bacterial

Therapeutic:
Admit to Internal Medicine ward with IV antibiotics and pain management
medications. Kept patient in Nothing per mouth.
1. Rosephin 1mg IV daily
2. Cephulac 30 ml oral evefry 6 hrs

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3.
4.
5.
6.
7.
8.

Lasix 40 ml oral daily

Aldactone 100mg oral daily
Tranexene 3.72 mg oral daily
Vasotec 1.25 mg IV every 6 hrs PRN BP > 160/90
Lovenox 40 mg subcutaneous daily
Albumin 25mg IV every 8 hrs

Problem List:
1. Tensional Ascites
2. Descompensated chronic liver
3. Left pleural effusion
4. Electrolyte imbalance
5. Hyponatremia
6. Chronic ethanolism
7. Facial melanoma resection by history
Rehabilitation:
1. Return to internal medicine outpatient clinic in 2 weeks.
2. Physical activity as tolerated.
Patient family education:
1. Educate patient and family on importance of being compliant with
treatment. Explain risk and benefits. Reach for an understanding and
agreement of the above.
Ethical Issues:
1. Autonomy, beneficence and justice were established and
maintained.
2. Patient confidentiality must be maintained at all times and patient
privacy must be respected.