Date:
Patient:
** admitting diagnosis:** (e.g., cirrhosis, alcoholic hepatitis)
HPI (History of Present Illness):
Summarize the patient’s current presentation, including:
Onset and duration of symptoms (e.g., abdominal pain, ascites, fever, chills)
Severity and character of symptoms
Any recent procedures or hospitalizations
Prior episodes of SBP
PMH (Past Medical History):
Focus on relevant medical history, including:
Underlying liver disease (e.g., cirrhosis etiology)
Previous episodes of ascites or SBP
Comorbidities (e.g., diabetes, renal failure)
Medications (especially diuretics)
Physical Exam:
Vital signs (including temperature)
General appearance (e.g., jaundice, ascites)
Abdominal exam (distention, tenderness, ascites)
Neurological exam (altered mental status)
Labs:
CBC (complete blood count) with differential (looking for leukocytosis)
Ascites fluid analysis:
Cell count (elevated neutrophils suggestive of SBP)
Protein
Glucose
Microbiology (culture and sensitivities)
LFTs (liver function tests)
Renal function tests
Imaging:
Abdominal ultrasound (may show ascites)
Diagnosis:
Spontaneous bacterial peritonitis (SBP)
Plan:
Antibiotics (broad-spectrum empiric therapy based on local resistance patterns)
Albumin replacement (if indicated)
Diuretics (consider after improvement in ascites infection)
Paracentesis (repeated if needed)
Consider referral to gastroenterology or hepatology for further management
Progress Notes:
Document daily progress including:
Response to treatment (improvement in symptoms, vitals, lab values)
Changes in medication regimen
Any complications
Discharge Planning:
Antibiotic completion plan (oral vs. IV)
Follow-up with primary care physician or gastroenterologist
Ascites management plan (diuretics, paracentesis)
Education on signs and symptoms of SBP recurrence
Note: This is a template and should be adapted to the specific patient’s presentation and course of treatment