Alcohol abuse, heavy alcohol consumption, patient is aware that this is most likely precipitating cause and decreasing alcohol intake is beneficial-Patient counseled to avoid alcohol.
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1. Pancreatitis - normal saline IVF at 200 cc/hr. Patient counseled on low-fat diet on discharge and avoiding alcohol as this can precipitate pancreatitis. Optimum diabetes management to avoid hypertriglyceridemia.
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Pancreatitis - lactated ringer's IVF at 200 cc/hr for up to 4 liters in the first 24 hours after admission. Patient counseled on low-fat diet on discharge and avoiding alcohol as this can precipitate pancreatitis. Pancreatitis most likely due to alcohol.
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Hematemesis -
Differential diagnosis includes gastric ulcer and esophageal varices.
Risks/benefits of EGD with possible variceal banding discussed with patient and family including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. Patient counseled on avoiding alcohol use.
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Await pathology results. The patient should be on Pantoprazole 40 mg p.o. BID for six weeks on discharge. The patient needs to follow up with me [] to discuss a repeat EGD in 6 weeks. Message was sent to clinic for follow up. Most likely source of bleeding was the gastric and duodenal ulcers. Avoid alcohol and NSAIDs. Differential diagnosis for gastric ulcer includes gastric cancer although less likely. Differential for gastritis includes H. Pylori infection
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Alcoholic cirrhosis - ascites, hepatic encephalopathy. Ordered cirrhosis panel, ascites panel, and AFP. Lactulose titrated to 3 bowel movements per day. Discharge on spironolactone 100 mg PO qday and Lasix 40 mg PO qday. Can follow up with me in clinic to discuss EGD with possible variceal banding. Gastroenterology will sign off. Please call with questions.
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Hematemesis -
Differential diagnosis includes gastric ulcer and esophageal varices.
Risks/benefits of upper endoscopy with possible variceal banding discussed with patient[] including bleeding, infection, perforation, and death. Patient agreeable to proceed with upper endoscopy. Patient counseled on avoiding alcohol use.
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Untreated patients with severe alcoholic hepatitis have a particularly poor prognosis, with one-month mortality rates ranging from 30% to 50%
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ICD 10 Diagnosis for Gastroenterology. Inpatient Gastroenterology. Hematemesis, hematochezia, melena, acute blood loss anemia, elevated liver enzymes, dysphagia esophagopharyngeal, epigastric abdominal pain, right upper quadrant abdominal pain, left upper quadrant abdominal pain, right lower quadrant abdominal pain, abnormal CT, ascites, hepatic encephalopathy, alcoholic cirrhosis, non-alcoholic cirrhosis, C. difficile diarrhea, acute pancreatitis, chronic pancreatitis, biliary pancreatitis, cannabis hyperemesis syndrome, cyclic vomiting syndrome, abnormal intraoperative cholangiogram.
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Significant elevations of serum lipase not caused by pancreatitis: a systematic review. Drugs, alcohol, type 1 diabetes mellitus.
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Enter your health infomration by copying and pasting the form below. Entries are permanent. HPI: Enter your main current problems including length of time, location, alleviating and exacerbating factors PMH: Enter your past medical history including prior diagnosis such as hypertension and surgeries. Medications: Enter your current list of medications Allergies: Family History: medical history in your family Social History: Tobacco, Drugs, Alcohol ROS: any other symptoms Labs, Radiology, Procedures: Enter prior labs, x-rays, CT scans, endoscopies, or other procedures. Physical: Enter any physical findings you've noticed Assessment/Plan: Enter working assessments and what you would like to gain from posting this information.
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