J.H ; Female ; 71yrs

Past Medical History

NASH Liver Cirrhosis

Dislipidemia

Gout

Angioplasty

Resulting in

Defined as

A type of liver scarring and injury resulting in an inflammed liver with the presence of fat accumulation

Anemia

As shown by

Hgb: 78

Iron: 6,3

Patient presented with

Asterixis

Puritus

Ascites

Lower limb edema

As a result of

Inadequate red blood cell production by the liver

As a result of

Increase portal pressure

Hypolalbuminemia

Resulting in a

Push of protein into the pertioneal cavity

Resulting in

An increase in fluids in the peritoneal cavity and lower limbs

causing

A decrease in colloidal oncotic pressure

Admitting diagnoses

Rib fracture after falling

Causing

Hepatic encephalopathy

defined as

A neuropsychiatric manifestation of cirrhosis

caused by

A build up of ammonia which is unable to be converted into urea & excreted via the kidneys

Treated with

Lactulose

works by

Binding to excess ammonia and excreting it through bowel movements

Managed by

Managed by

Paracentesis

Possible Hepatorenal Syndrome

caused by

Bile salts getting trapped under the skin

defined as

An invulontary reaction of rapid flexion and extension

defined as

An injury to the kidneys as a result of longterm portal hypertension and possible systemic vasodilation

reuslting in

Decreasing arterial blood volume to the kidneys

A result of

Due to

Diuretics

Furosemide

Spironolactone

resulting in

Kidney injury

as evidence by

Oliguria & Bladder scan of 400mL

works as

D/C due to

Createnine 241

A potassium sparring diuretic

managed by

Albumin transfusion

Assessment findings

Positive fluid wave test (Abnormal)

BS + x4

Tympany x4 quadrants

Monitor for 3-4 stools per day

monitor for

urine retention

Lower back pain (5/10 or more) with peristent and increasing pain

Increasing BUN and serum creat.

Monitor for peri-rectal burns and agitation due to loose stools

assessment finds

Increase in somnelence (abnormaL)

CABG

defined as

Removing peritoneal fluid excess via inserting a needle into the pertoneal cavity

priority problem

Gastrointestinal bleed

Monitor for signs of dehydration

Monitor for

Rashes

purirutus

Increase WOB or SOB

Monitor

Serum potassium levels

Proteinuria, glucose in urine

Nausea & vomiting

Managed by

Ondansetron

Functions by

Blocking chemical triggers of nausea and vomiting

Due to

Portal hypertension

Assessment finding

Dilaudid 0,5mg IV

Patient presented with signs of

Hypertension of 145/85 or greater

(Im sorry I can't connect it to the other symptoms I'll just rewrite them)

Acites

Edema of the lower limbs

Hepatic encephalopathy

Monitor for

Melena

Frank blood from the mouth

Causing

Varices

Vomiting 'coffee ground' type

defined as

Swollen or engorged veins in the stomach or espohagus due to portal hypertension

Pallor

Change in LOC (late sign)

Causing

Decrease of coagulation factors

managed by

Vitamin K suppliment PO

Helps by

Assisting certain coagulation factors into mature forms

RED: Pmhx and definiton. / TEAL: Labs. / ORANGE: monitoring / PINK: Signs and symtpoms. / GREY: Abnormal findings. / GREEN: Medications. / BLUE: PP and admiting dx