BSU Liver Cirrhosis Case Study answer the case study questions and do a PowerPoint slides with the case study attached below CASE STUDY 18 CIRRHOSIS For th

BSU Liver Cirrhosis Case Study answer the case study questions and do a PowerPoint slides with the case study attached below CASE STUDY
18
CIRRHOSIS
For the Disease Summary for this case study,
see the CD-ROM.
PATIENT CASE
Patient’s Chief Complaints
Provided by wife: “My husband’s very confused and he has been acting strangely. This morn-
ing, he couldn’t answer my questions and seemed not to recognize me. I think that his stom-
ach has been swelling up again, too. He stopped drinking four years ago, but his cirrhosis
seems to be getting worse.”
а HPI
S.G. is a 46 yo white male with a history of chronic alcoholism and alcoholic cirrhosis. He
was admitted to the hospital from the outpatient clinic with abdominal swelling and con-
fusion. He has unintentionally gained 15 lbs during the past four weeks. According to his
wife, the patient has not been sleeping well for several weeks, has been feeling very lethar-
gic for the past three days, can’t seem to remember appointments lately, and, uncharac-
teristically, has lost his temper with her several times in the last month. S.G.’s boss at work
had also telephoned her last week concerned about his “unusual and violent behavior on
»
the job.
PMH
Pneumonia 9 years ago that resolved with antimicrobial therapy
Cirrhosis secondary to heavy alcohol use diagnosed 4 years ago with ultrasound and liver
biopsy (micronodular cirrhosis)
H/O uncontrolled ascites and peripheral edema
H/O two upper GI hemorrhages from esophageal varices
HO anemia
HO E. coli-induced bacterial peritonitis 4 years ago
H/O acute pancreatitis secondary to alcohol abuse
No history to suggest cardiac or gallbladder disease
No previous diagnosis of viral or autoimmune hepatitis
* GASTROINTESTINAL DISORDERS
82
Oth
SURG
PSGC 9126520
Do S/P appendectomy requiring blood transfusions 30 years ago
Baton S/P open-reduction internal fixation of right femur secondary to MVA 5 years ago
Homojo 1102
FH
• Father died at age 52 from liver disease of unknown etiology
• Mother had rheumatoid arthritis and ulcerative colitis, died from massive stroke at
age 66
• Maternal aunt, age 71, with Graves disease
• Patient has no siblings
15
ten
SU POLU
SH.
CE
• Educated through eighth grade
Department store men’s clothing manager and salesman, 17-year career
• Married for 19 years with 1 daughter, age 10
• H/O ethanol abuse, quit 5 years ago following MVA, previously drank 3 cases of beer/
week X 15 years
• H/O IVDA (heroin) and intranasal cocaine, quit 5 years ago
• Has smoked approximately 1/2 ppd for many years
Meds
Propranolol 10 mg po TID
• Spironolactone 50 mg po QD
• Furosemide 20 mg po QD
• MVI 1 tablet po QD
• Occasional ibuprofen or acetaminophen for headache
• Patient has H/O non-compliance with his medications
All
NKDA
ROS
Increasing abdominal girth
(-) complaints of abdominal pain, fever, chills, nausea, vomiting, hematemesis, tarry
stools, loss of appetite, cough, chest pain, SOB, lightheadedness, weakness, blood in the
urine, diarrhea, constipation, and dry mouth
Patient Case Question 1. Hematemesis and tarry stools are clinical signs of which seri-
ous potential complication of cirrhosis?
CASE STUDY 18 = CIRRHO
– PE and Lab Tests
Gen
obvious distress.
The patient is restless, mildly jaundiced, and disoriented to time, place, and people. He is
slow to answer questions and his answers make litte sense. He is ill-appearing but in no
VS
• BP 120/75, P 83 and regular (supine)
• BP 118/70, P 80 and regular (standing)
• RR 14 and unlabored
• T 98.8°F orally
• WT 171 lbs
HT 5 ft-7 in
• SaO2 = 97%
Skin
• Warm, dry, and well perfused with normal turgor
• Mild jaundice
(+) spider nevi on chest
(-) palmar erythema
• Several ecchymoses on lower extremities
• Large “Cobra” tattoo on right upper arm
HEENT
(-) bruises, masses, and deformities on head
(+) icteric sclera
Pupils at 3 mm and reactive to light
EOMI
Funduscopic exam WNL
TMs clear and intact
O/P pink, clear, and moist without erythema or lesions
Neck/LN
Supple
(-) JVD
goiter, thyroid nodules, carotid bruits, and adenopathy
Chest
Lungs CTA bilaterally without wheezes or crackles
Diaphragmatic excursions WNL
Good air exchange
(+) gynecomastia
Heart
RRR
Normal S, and S, with no S, or S4
No m/r/g heard
GASTROINTESTINAL DISORDERS
PART 3
Abd
Moderately distended, firm, and slightly tender
(+) prominent veins observed around umbilicus
(+) HSM
• Active BS
• (-) guarding, rebound tenderness, palpable masses, and aortic, iliac, and renal bruits
Genit/Rect
Heme-negative stool
• Penis normal, testicles moderately atrophic but without masses
Normal sphincter tone
(+) hemorrhoids
• Prostate may be slightly enlarged but (-) for nodules and tenderness
MS/Ext
• No clubbing or edema
• Good peripheral pulses at 2+ throughout
Normal range of motion throughout
Neuro
• CNs grossly intact
• Brisk DTRs at 2+
Slight asterixis noted
Strength is equal bilaterally
• Confused and disoriented
Negative Babinski
• Sensory grossly intact
Patient Case Question 2. Identify a minimum of 15 clinical signs and symptoms that are
consistent with a diagnosis of cirrhosis.
Laboratory Blood Test Results
See Patient Case Table 18.1
Patient Case Table 18.1 Laboratory Blood Test Results
Na
WBC
135 meq/L
1.7 mg/dL
4,700/mm
Mg
K
PT
90 ng/mL
15.6 sec
AFP
3.5 meq/L
cl
PTT
101 meq/L
(-)
45.1 sec
HBsAg
HIV
NH,
HCO3
(-)
250 pg/dL
25 meq/L
Anti-HCV
107 IU/L
AST
(+)
12 mg/dL
BUN
2.8 million/mL
86 IU/L
ALT
0.6 mg/dL
HCV RNA
Cr
224 IU/L ANA
Alk Phos
(-)
90 mg/dL
Glu, fasting
Bilirubin
Fe
2.4 mg/dL
75 g/dl
14.0 g/dL
Hb
200 ng/mL
Ferritin
6.6 g/dL
Protein
39.7%
Hct
Transferrin saturation 389
2.7 g/dL
Alb
MCV
Ceruloplasmin
37 mg/d
8.5 mg/dL
34,500/mm Ca
Plt
90 fL
CASE STUDY 18 * CIRRHOSIS
CBC has revealed?
Patient Case Question 3. Is the patient anemic at this time and, if so, is the anemia
normocytic, microcytic, or macrocytic?
Patient Case Question 4. What is the most significant abnormality that this patient’s
Patient Case Question 5. Based on the laboratory data, why has this patient’s cirrhosis
shown a sudden and unexpected progression?
Patient Case Question 6. Identify four risk factors that
patient’s current condition.
contributed to this
may have
Patient Case Question 7. Why can bacterial peritonitis be ruled out as a current poten-
primary health care
contributing
out as a
tial diagnosis?
Patient Case Question 8. What justification might the patient’s
provider have for conducting an ANA test?
Patient Case Question 9. Why can hemochromatosis be ruled
factor to this patient’s condition?
Patient Case Question 10. Why can Wilson disease be ruled out as a
to this patient’s condition?
be ruled out as contributing factors to this patient’s condition?
contributing factor
Patient Case Question 11. Why can autoimmune hepatitis and primary biliary cirrhosis
Osteoporosis?
Patient Case Question 12. Is there any evidence that this patient is at high risk for
with ascites.
Patient Case Question 13. Identify two abnormal laboratory tests that are consistent
Patient Case Question 14. Which single laboratory test strongly suggests that the patient
has developed hepatic encephalopathy?
Patient Case Question 15. How would you grade this patient’s encephalopathy?
Patient Case Question 16. What is this patient’s CTP score?
Patient Case Question 17. What is the probability that this patient will live for one year?
Patient Case Question 18. Does this patient have any signs of dehydration or hepatorenal
syndrome?
Patient Case Question 19. The patient’s primary care provider has decided to conduct
extensive clinical studies for the diagnosis of liver cancer. Which single abnormal labora-
tory value has raised a concern that hepatocellular carcinoma may have developed?

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