Patient Name: Sean Richards
Age: 45 years
Admitting Diagnosis: Cirrhosis with bleeding esophageal varices secondary to portal hypertension
Admission Assessment performed by: Dr. Al Bumin
Chief Complaint:
Vomiting blood, abdominal distention, and fatigue.
History of Present Illness (HPI):
Mr. Sean Richards is a 45-year-old male who presented to the emergency department with complaints of hematemesis that began early this morning. The patient reports initially vomiting “coffee-ground” material followed by bright red blood. He also notes worsening abdominal distention, generalized fatigue, and poor appetite over the past month. He denies alcohol consumption in the last week but admits to episodic binge drinking on most weekends. He has experienced nausea and intermittent confusion over the past several days. He denies any melena or hematochezia.
Past Medical History (PMH):
Hepatitis C (diagnosed 10 years ago)
Alcoholic cirrhosis
Malnutrition
Past Surgical History (PSH):
None reported
Family History (FH):
Father: deceased, alcoholic liver disease
Mother: living, hypertension
Social History (SH):
Lives alone in an apartment
Unemployed; lacks health insurance
History of heroin use (abstinent for 2 years)
Admits to weekend binge drinking
Denies tobacco use
Diet reported as poor, with minimal protein intake
Allergies:
No known drug or food allergies (NKDA/NKFA)
Medications (prior to admission):
None routinely taken
PHYSICAL (P)
Admission Assessment performed by: Dr. Al Bumin
Vital Signs on Admission:
BP: 94/56 mmHg
HR: 120 bpm
RR: 22 breaths/min
Temp: 100.5°F (38.1°C)
O₂ Sat: 95% on room air
General Appearance:
Thin, undernourished male appearing fatigued and mildly confused. Skin pale with yellow discoloration of sclera.
HEENT:
Scleral icterus noted. Oral mucosa tacky and dry. No active bleeding noted in oropharynx.
Cardiovascular:
Tachycardic with regular rhythm. Peripheral pulses weak but palpable. 1+ pitting edema in lower extremities.
Respiratory:
Breathing unlabored, lung sounds clear bilaterally. No adventitious sounds.
Gastrointestinal:
Abdomen distended and firm with dullness to percussion; mild tenderness in the right upper quadrant. Bowel sounds audible in all quadrants. Nasogastric tube in place with coffee-ground output.
Genitourinary:
Voiding small amounts of dark amber urine (approximately 30–40 mL/hr).
Neurological:
A/O × 4 but intermittently lethargic. Mild asterixis noted.
Skin:
Jaundiced with large ecchymosis on lower abdomen. Skin warm, slightly clammy.
Assessment Summary:
45-year-old male with a history of hepatitis C and chronic alcohol use, presenting with hematemesis and hemodynamic instability consistent with upper gastrointestinal bleeding likely due to ruptured esophageal varices secondary to portal hypertension. Labs reveal anemia (Hgb 8.0 g/dL), thrombocytopenia, elevated INR, and hyperbilirubinemia, confirming decompensated cirrhosis. The patient is currently at risk for hypovolemic shock and hepatic encephalopathy.