SUBJECTIVE: The patient came here because of increased white blood cells. The patient has liver cirrhosis that was found on the last CAT scan of her abdomen and some ascites. Perhaps, the patient has spontaneous bacterial peritonitis.
The patient today complains of some dry cough and some chills. She says she has also some stomach pain but only when she is coughing. On palpation, she does not have any pain in her stomach. Denies any nausea, any vomiting, any fever at home.
We would like the patient to go to the hospital and that was explained extensively to the patient and the husband, who was in the room, because for spontaneous bacterial peritonitis the best way to get antibiotics is intravenously. Also, we could check her ascitic fluid and we could send it for analysis. The patient does not want to do that. She understands the risks of that.
We recommended that she go to the ER anytime that she is feeling any worse. We are going to give her today here a shot of Rocephin 1 gram IM. We are starting her on Cipro 500 mg p.o. b.i.d. for 10 days. She will come again tomorrow here for another shot of Rocephin 1 gram IM, and we will check her white blood cells tomorrow and her white blood cells on Monday.
The patient was explained that at any time if symptoms get worse to go immediately to the hospital and we will admit her there.
OBJECTIVE:
VITAL SIGNS: Blood pressure 118/62, pulse 62, respiratory rate 20, temperature 97.4, and weight 120 pounds.
GENERAL: Alert, awake, oriented, elderly Hispanic female in no acute distress currently.
LUNGS: There are some decreased breath sounds on the left base, otherwise unremarkable.
HEART: Regular rate and rhythm. S1, S2.
ABDOMEN: Positive bowel sounds. There is mild distention. Nontender to palpation.
EXTREMITIES: There is 2-3+ edema in both lower extremities, left slightly worse than right.
ASSESSMENT AND PLAN:
1. Increased white blood cells, question of spontaneous bacterial peritonitis. As mentioned above, we had a long discussion with the patient, about 40 minutes. She does not want to go to the hospital. We recommended for her to go to the hospital and be admitted there and be on IV antibiotics for a couple of days. She prefers to not do that. She understands the risks of that. We are going to give her Rocephin IM dose today, tomorrow, and also Cipro 500 mg p.o. b.i.d., and we are going to follow her white blood cell counts. The patient was explained that if at any point she feels worse or she changes her mind, to go to the ER and she will admitted there.
2. Liver cirrhosis. She has an appointment with GI. The patient is off tamoxifen. Her liver enzymes are doing better.
3. Lower extremity swelling, could be coming from the liver. She is on Lasix 20 mg b.i.d., but her legs are still swollen. We are going to follow up on that.
4. Paroxysmal atrial fibrillation, off Coumadin. Her rate is controlled.
5. Hyperthyroidism. The patient is off amiodarone. Probably, it was amiodarone induced. Her last blood work showed slightly increased free T4 but much better than it was before. The patient was recommended to be on metoprolol for rate control and also for tremors.
6. History of right breast cancer, off tamoxifen. As mentioned above, liver enzymes are doing better.
7. Osteoporosis, on calcium supplementation and also Fosamax. We do not know if she takes Fosamax. She brought just her Lasix today and potassium. We are more concerned about her white blood cells today than anything else.
8. We are going to follow up with the patient, if she does not go to the hospital. Otherwise, we are going to see her in the hospital. The patient, as mentioned above, did not want to go to the hospital and that was discussed with both her and her husband.
