Clinical Discharge 652

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Academic Clinical Discharge Summary Note

Muhammad Aftkhar

Grand Canyon University

February 15th, 2021

Academic Clinical Discharge Summary Note

Reason for admission

A 62 years old male patient came with a dull throbbing pain in the right upper abdominal region. The patient was somewhat nervous due to stabbing pain. The pain scale was eight. The patient reached the hospital with his daughter. Upon physical examination, there was swelling on the upper right abdomen and pain radiating towards the shoulder blade. The other reported symptoms were fatigue, yellowing of the skin, loss of appetite, and swollen ankles (Chen, et al., 2020). Laparoscopic examination of the liver suggested that focal hepatocellular necrosis was present. Additionally, Nodular regeneration and distortion of hepatic texture were also observed. Macronodules with a size of 5 mm were also observed. Moreover, Ultrasound indicated the surface nodularity with 88% sensitivity.

ICD 10 Diagnosis

· Liver cirrhosis (K74.60)

· Celiac disease (K90)

· Autoimmune hepatitis (K75.4)

· Hepatocellular carcinoma (155)

· Primary biliary cirrhosis (K74.3)

List of all procedures:

· Band ligation (CPT Code = 46221)

· Transjugular intrahepatic portosystemic shunting (TIPS) (CPT Code = 37182)

· Splenorenal shunt (CPT Code = 37205)

· Paracentesis (CPT Code = 49082)

· Liver transplantation (CPT Code = 47135)

The progression of liver cirrhosis often results in portal hypertension that ultimately led to esophageal varices. When the portal pressure increases from 7 mmHg, variceal bleeding occurs. Therefore, Variceal band ligation is the primary procedure to manage the complications. Similarly, TIPS is used to control variceal bleeding to increase the survival of the patient. Moreover, the splenorenal shunt is used to limit the recurrent variceal hemorrhage. When the patient has a splenorenal shunt, there is significant control of portal hypertension. In this surgical procedure, the patient is also given general anesthesia, and the vein from the spleen is disconnected from the portal vein and re-joined to the renal vein. However, when all the mentioned procedures become ineffective, then hepatic transplantation is required to replace the fibrotic part of the liver with a healthy liver. All the procedures make use of contrasted enhanced intraoperative ultrasonography.

Complete list of consults during hospitalization:

· Post-surgical consultation for pain management

· Instructions for TIPS to avoid any complications due to shunt.

· The physician consult for antibiotic to prevent infection from ascites

· Pharma consults for drug treatment

· Ascites drainage

· Vasoactive therapy

· Dietitian consults for diet modification or low salt diet

· Self-care plan provided nursing education plan.

Patient's condition at discharge:

Liver cirrhosis is a serious medical condition that is associated with certain common complications. The purpose of hospitalization is to reduce the gravity of the symptoms and pertinent complications. The patient is likely to discharge when portal hypertension is curbed by beta-blockers. The variceal bleeding is controlled and managed by band ligation surgery. The patient is negative for further ascites by diuretics therapy. Additionally, the patient has no pain in the upper gastric quadrant as portal hypertension is controlled. The patient is exhibiting full compliance with the diet plan and takes food with low sodium intake. However, the patient is further compliant with the liver-friendly diet, such as vegetables and fruits. The blood test shows a relatively low level of liver enzymes, bilirubin, normal protein levels, and the absence of bacterial infections (De Munck, et al., 2020). The patient has done his vaccines for flu, and pneumonia.

Complete physical exam at discharge

Subjective

The nursing staff reported the physical appearance of the patient. They mentioned that there was no sign of stress or discomfort. The patient behaved normally. The patient was quite energetic for his discharge. He was actively taking part in the discharge procedure. Additionally, the patient was confident that he would be comfortable with his family and decided not to go to any nursing care center. The family members of the patients were rather concerned. They wanted to give him complete nursing care at home. The medical team was also agreed to the suggestion of home care of the patient.

Objective

Temp: 36.7 C; BP: 115/78; HR: 80; RR; O2 Saturation: 99%; Pulse: 90bpm

Physical Examination

General appearance

Normal appearance with no signs of anxiety and stress.

HEENT

PERRLA, no cervical LAD, no thyromegaly, normal tympanic membrane, oral mucosa normal, no throat infection, normal nasal passage.

Cardiovascular

No chest pains, no edema, no palpitations

Respiratory

No wheezing, clubbing, no chest discomfort, normal breathing

Gastrointestinal

No abdominal pain, no bloating, no digestive problems.

Genitourinary

No dysuria, hematuria, or polyuria.

Musculoskeletal

The normal range of motion, no muscular abnormalities, normal body posture.

Integumentary

No bruise, no physical injury.

Extremities

No cyanosis, no clubbing.

Neurological

No dizziness, no vertigo.

Psychiatric

No signs of stress, anxiety, and depression. Normal mood.

What diagnostic criteria confirmed the discharge diagnosis?

The diagnostic criteria for liver cirrhosis involve the absence of a set of symptoms such as pain in the upper abdominal region just beneath the ribs and swelling and tenderness.

Complete list of discharge medications:

· Nadolol 40 mg BD

· Tenofovir 25 mg BD

· Lasix, 20 mg OD

· Neomycin 500 mg BD

Pending test results for follow up

1. Alanine transaminase (ALT) (CPT code = 84460)

Reference range = 4 IU/L to 43 IU/L

2. Alkaline phosphatase (ALP) (CPT code = 001107)

Reference range = 44IU/L to 147 IU/L

3. Aspartate Aminotransferase (AST) (CPT code = 001123)

Reference range = 7 IU/L to 38 IU/L

4. Sodium blood test (CPT Code=001198)

Reference range 135mEq/L to 145 mEq/L

5. Serum Albumin test (CPT Code= 82040)

Reference range = 3.8 g/dl to 5.1 g/dl

6. Serum Bilirubin test (CPT Code= 82248)

Reference range = 0.2 mg/dl to 1 mg/dl

7. CT scan (CPT Code= 74176)

8. Elastography (CPT Code= 76981)

Complete list of any pathology

· Edema (R 60.9)

· Portal hypertension (K 76.6)

· Ascites (R 18.8)

· Bacteremia (R 78.81)

Who is responsible for follow-up on final results?

The results of the test that has been ordered are directly related to the patient and some extent to the providers. The results require the active involvement of the patient. Therefore, patients are more responsible for the final results.

Complete list of discharge instructions:

· Cessation of alcohol

· Diet modification with cut back on salt

· Limit canned and fast foods

· High protein intake

· Weight management

· Medication as directed by the physicians

· Avoid aspirin or blood-thinning drugs.

· Vaccinations regarding liver disease

· Slow walking

· Try to reduce stress.

· Avoid having constipation

· Antibiotics for bacteremia

· Sufficient rest and exercise (Muley, et al., 2020)

Complete list of discharge follow-ups

· Lab test for likely blood infections

· Blood test for liver cancer

· Ultrasound and CT scan of the liver every six months

· Endoscopy for varices

· Evaluation of band ligation

· Refer to hepatologist if gastrointestinal bleeding occurs

· Minimum one-month follow-up appointments.

What were the diagnostic criteria needed after discharge?

· Bruising or bleeding

· Fluid buildup in the belly

· Edema in extremities

· Jaundice

· Blood in vomit

· Pain and variceal bleeding

· Disturbance in shunt

· Black stools

· Breathing problems and fatigue

Summary

What questions were raised during the hospital stay?

1.How effectively hospital care reduces the symptoms of liver cirrhosis and improve the liver function

The patient with liver cirrhosis should avoid alcohol; in this way, they can limit the onset of alcohol-induced liver cirrhosis. Moreover, the surgical intervention during hospital stay controls the complications of portal hypertension.

2.What are the protocols that limit the chance of readmission?

Patient compliance with the medication and active participation in follow-up guidelines limit the probability of readmission.

What questions were raised that required further exploration?

1. What are the prophylaxis therapies for liver cirrhosis?

2. What is the Prognosis of Band ligation and splenorenal shunt?

3. What is the life expectancy of the patient with liver transplantation?

What kind of discharge planning did you need?

My discharge plan must include:

· Information about family care and nursing care

· Nursing education plan

· A simple and comprehensive discharge plan

· Complete information about diet modification and physical exercise

· Detailed information about medication and the importance of compliance

· Detail instruction about the regular follow-ups

Characterize your patient interaction activities.

· Effective communication with the patient

· Rapport

· Empathy

· Collaboration

· Technology

· Nonverbal communication

· Open-ended questions

· Probing questions

Overall assessment

Identify health promotions

Health promotion activities enable people to control their health issues and determinants to improve their health. Liver cirrhosis health promotion includes healthy eating habits, healthy liver practices such as cessation of alcohol abuse.

Health education

This is an educational practice that educates people about health. Liver cirrhosis health education includes diet modification, limited salt intake, and an increase in protein diet.

Ethical considerations

These are the set of ethics applied during the treatment of a patient that gives him autonomy, informed consent, voluntary participation, and confidentiality, and power of decision-making regarding certain medical interventions.

Geriatric considerations

Geriatric patients require extra medical care and need multiple health care providers. It focuses on the health care of geriatric patients to improve health, prevent disease progression, and assist the disabilities in older patients.

Expected outcomes.

The outcomes are related to the provided considerations as the health care system involves many stages of treatment and a group of people. All these parameters affect the expected outcomes of the treatment.

References

Chen, K., Sng, W. K., Quah, J. H. M., Liu, J., Chong, B. Y., Lee, H. K., ... & Bee, Y. M. (2020). Clinical spectrum of nonalcoholic fatty liver disease in patients with diabetes mellitus. Plos one, 15(8), e0236977.

De Munck, T. J., Xu, P., Verwijs, H. J., Masclee, A. A., Jonkers, D., Verbeek, J., & Koek, G. H. (2020). Intestinal permeability in human nonalcoholic fatty liver disease: A systematic review and meta‐analysis. Liver International, 40(12), 2906-2916.

Muley, M., Vespasiani-Gentilucci, U., De Vincentis, A., Santonico, M., Pennazza, G., Sanguedolce, S., ... & Antonelli-Incalzi, R. (2020). Voltammetric analysis for distinguishing portal hypertension-related from malignancy-related ascites: A proof of concept study. Plos one, 15(5), e0233350.