The patient is a 46-year-old female who is two months post uncomplicated deceased donor liver transplant for nonalcoholic steatohepatitis (NASH) cirrhosis

QUESTION

A 46 y.o. female who is two-months status post uncomplicated deceased donor liver transplant due to nonalcoholic steatohepatitis (NASH) cirrhosis is transferred from an outside hospital (OSH) to tertiary care for confusion and anasarca. You are unable to obtain ROS from the patient due to confusion. The chart review reveals no allergies. EMR has the patient taking tacrolimus, mycophenolate, and prednisone for the transplant. Examination reveals BP 141/78, temp 37.9 oral, HR 99 BPM, RR 16, and 91% on RA. Does not appear in distress, atraumatic/normocephalic, PERRLA, moist mucous membranes, regular rate and rhythm, no murmurs. 2 pitting edema bilaterally to thighs with ascites and HJR. Abdomen distended with normoactive bowel sounds and non-tender with palpation. Fluid shift observed. No rashes or lesions but jaundice appearing. Lungs have bilateral rales. Overall generalized weakness with no focal deficits. Oriented to self only and short attention span. ECG normal sinus rhythm. Labs: WBC 14.8, Hemoglobin 7.4, Platelet 57, Sodium 129, Potassium 4.8, Cl- 105, CO2 34, BUN 34, Cr 1.2, and glucose 78. Positive occult blood on rectal exam. LFTs are pending. Questions: Construct the patient’s data into a SOAP Note format (see template). If there is missing information, include what you

ANSWER

Subjective

The patient is a 46-year-old female who is two months post uncomplicated deceased donor liver transplant for nonalcoholic steatohepatitis (NASH) cirrhosis. She was transferred from an outside hospital (OSH) to tertiary care due to confusion and anasarca. No allergies reported.

Objective

Vital Signs: BP 141/78, temp 37.9°C oral, HR 99 BPM, RR 16, SpO2 91% on RA.
General: Patient does not appear in distress.
Neurological: Patient is oriented to self only, has a short attention span, and exhibits overall generalized weakness with no focal deficits.
Eyes: Pupils are equal, round, and reactive to light. Extraocular movements are intact.
ENT: Moist mucous membranes.
Cardiovascular: Regular rate and rhythm, no murmurs.
Respiratory: Bilateral rales, lungs clear to auscultation.
Gastrointestinal: Abdomen distended, normoactive bowel sounds, non-tender to palpation. Positive fluid shift observed. 2 pitting edema bilaterally to thighs with ascites and hepatojugular reflex.
Skin: No rashes or lesions, but jaundice apparent.
Extremities: No cyanosis, clubbing, or edema.
Musculoskeletal: No deformities or limitations in range of motion.
ECG: Normal sinus rhythm.
Labs: WBC 14.8, Hemoglobin 7.4, Platelet 57, Sodium 129, Potassium 4.8, Cl- 105, CO2 34, BUN 34, Cr 1.2, Glucose 78. Positive occult blood on rectal exam. LFTs pending.

Assessment

The patient is a 46-year-old female with a history of NASH cirrhosis who is two months post deceased donor liver transplant. She presents with confusion and anasarca, along with jaundice and generalized weakness. Positive fluid shift, pitting edema, and hepatojugular reflex observed. Labs show anemia, thrombocytopenia, hyponatremia, hypokalemia, hypochloremia, elevated BUN, and mildly elevated creatinine. Positive occult blood on rectal exam.

Plan

1. Further assess and monitor patient’s neurological status.
2. Initiate oxygen therapy to improve SpO2.
3. Administer blood transfusion for anemia.
4. Provide diuretic therapy to manage fluid overload and ascites.
5. Monitor and correct electrolyte imbalances.
6. Complete pending LFTs to assess liver function.
7. Consider consultation with hepatology for further evaluation and management of post-transplant complications.
8. Initiate frequent repositioning and skin care measures to prevent pressure ulcers due to pitting edema.
9. Monitor patient’s response to interventions and adjust as needed.