Assignment On Cirrhosis and Ascites

SOAPE
Student’s name:
Institutional:

Subjective
DG is a 58-year old male who is visiting his PCP for follow -up after having been discharged
from hospital for the treatment of spontaneous bacterial peritonitis (SBP). He has alcoholic liver
disease.
PMH: Alcoholic liver disease with cirrhosis and ascites, encephalopathy, portal hypertension and
osteoarthritis in both knees.
FH: Has no contribution
SH: He denies having used illicit drugs. He also quit smoking 20 years ago and have not taken
alcohol for 6 months.
HEENT: Has no icterus. Nystagmus PEERLA, EOMI present.
Medications
Cipro 500mg PO BID completed a 7-day course
Propranolol 20 mg PO BID
Spironolactone 50 mg PO daily
Furosemide 20 mg PO daily
Objective
Vital signs: BP 120/70 mmHg, HR 72, RR 16, T 99F
Wt 100kg ht 5’10”
Lung CTA
Heart RRR no m/r/g Abd + ASCITES
No evidence of Jaundice or edema Asterixis present
He also had a shuffling walk and trouble remembering three words.
Na – 138mEq/L, K- 3.8mEq/L, Cl- 99 mEq/L, BUN- 10 mm/dL WBC – 5.6 x 103/mm3