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Essay Details:
Essay text:
Pt also has jaundice. Pt came into the ED for increasing jaundice and abdominal pain secondary to increasing distention of the abdomen. This has not been acute but has been an accumulative process.
Significant Medical History:
Significant for liver cirrhosis, diabetes mellitus type 2, alcohol abuse, and chronic pancreatitis. Pt states she has not been on medications for one year.
Primary Diagnosis:
Tense ascites due to cirrhosis
Surgical Procedure and Date (if any at this admission):
Diet Ordered: Rationale:
Diab-sodium control 1800cal, 2 gm NA Low NA to reduce fluid retention (ascites)
Activity Level: Rationale:
Bed rest To get rid of the fluid from lower extremities
Lab Procedures ordered: (Results on back)
Xtra pink-draw & hold; LDH, peritoneal; Albumin, peritoneal; Protein total, peritoneal; Hemoglobin A1C; Culture bacterial, U midstream; Sodium, random UR
Other Tests: (Results on back)
DUS: Paracentesis (Dx ascites)
DUS: leg-useven, bilateral, eval for DVT
Allergies: (Include reaction) Code Status:
No known allergies Full code
LAB VALUES ON ADMIT, MOST RECENT AND NORMAL VALUES FOR THE INSTITUTION...
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