Skip to Main Content

PATIENT PRESENTATION

Chief Complaint

“My belly keeps filling with fluid, and I don’t feel well.”

History of Present Illness

SB is a 49-year-old female with a PMH of HCV who presented with complaints of sharp, constant abdominal pain and swelling.

Past Medical History

Childhood Illnesses

Measles at age 5, recurrent OM

Travel

Recent trip to Arizona

Habits

+ EtOH, (–) tobacco, (–) illicits

Immunizations

Up-to-date on all childhood immunizations

Surgical History

Two pins in R great toe s/p bunion repair

Family History

Mother: MI, DM2, dyslipidemia, obesity

Father: DM2, obesity, deceased at age 50

Social History

SB currently lives with her mother. She works a full-time job as a teller at the local credit union.

Allergies

NKDA

Home Medications

None

Physical Examination

General Appearance

Cachectic appearing female in NAD, supine in bed

Vital Signs

Temp 101.5°F, HR 80, BP 108/72, RR 16 breaths per minute, SpO2 98% RA, Ht 5′4″, Wt 46 kg

Skin, Hair, and Nails

Jaundice, no rashes or bruises

HEENT

AT, bitemporal wasting, PERRL b/l, no ptosis, + scleral icterus, nares patent, MMM

Neck

Supple, NROM, + JVD

Chest and Lungs

CtAB, no w/r/r

Heart

RRR, no m/r/g, severe pitting edema to level of abdomen

Abdomen

Taut, distended, fluid wave, midline large hernia, caput medusae, RUQ guarding, hypoactive bs, massive ascites

Extremities

3+ pitting edema BLLE

Neurologic

Sensation intact, CN II-XII intact, strength 5/5 in UE and LE, + asterixis, + ataxia

Psychiatric

Appears confused, somnolent

Laboratory Findings

Chemistry, Coags, CBC

Favorite Table | Download (.pdf) | Print

Sodium (136–146) mmol/L

Potassium (3.5–5.1) mmol/L

Chloride (98–108) mmol/L

CO2 (20–30) mmol/L

BUN (7–17) mg/dL

Creatinine (0.5–1.2) mg/dL

Glucose (74–106) mg/dL

Calcium (8.4–10.2) mg/dL

122

4.1

96

20

20

1.87

86

9.1

T. Protein (6.6-8.7) g/dL

Albumin (3.5–5.5) g/dL

T. Bili (0–1) mg/dL

D. Bili (0–0.3) mg/dL

I. Bili (0–1.1) mg/dL

Alk Phos (40–129) U/L

AST (0–40) U/L

ALT (0–41) U/L

6.2

2.3

18.6

...

Pop-up div Successfully Displayed

This div only appears when the trigger link is hovered over. Otherwise it is hidden from view.