MODULE 3

CASE
DISCUSSION
ORDOÑEZ, PACIA, PAGLINAWAN, PAJARES, PANUMPANG, PELAYO
Pertinent Positives Pertinent Negatives

History History
General Data: Age, Gender - (-) Chest Pain/
CC: Loss of Consciousness orthopnea/ PND
HPI: - (-) Hematochezia
- 5 days PTA: (+) Diffuse abdominal pain
- Not related to: food intake, anorexia & low grade fever
- Self- medicated w/ Buscopan & Paracetamol (Minimal relief)
- 2 days PTA:
- (+) Dull abdominal pain and fever persistence
- (+) Drowsy, tired, and asleep most of the day
- Few hours PTA:
- (+) Inc. severity of abdominal pain
- Attempted to defecate
PMH: (+) HTN for 10 years [Takes Amlodipine 5 mg OD], (+) Hx of Abdominal Gunshot Wound [Underwent laparotomy 10 yrs PTA w/
blood transfusion], (+) Ibuprofen and diclofenac for knee pain
PSH: (+) 20 pack year smoker, (+) Drinks 5-6 beers and some gin [3-4x a week; 15 years]
ROS: (+) Dizziness, (+) Palpitations, (+) Dyspnea on exertion, (+) Melena, (+) Constipation, (+) Recurrent right knee pain

Physical Examination Physical Examination

- General: Awake but drowsy and weak looking - Able to answer some
- Vital Signs and Anthropometrics: BP: 100/80, HR: 110/min (Tachycardic), RR: 26/min (Tachypneic), Temp: 38.2C (Febrile), questions
BMI: 25.8 (Obese 1) - Liver span 6 cm at
- Skin and HEENT: (+) Jaundice, (+) Icteric sclerae, (+) Pale palpebral conjunctiva and nail beds, (+) Gynecomastia RMCL (Normal)
- Respiratory: (+) Dullness on percussion lung, (+) Decreased Breath Sounds on both basal lung fields - (-) Cervical
- Abdomen: (+) Distended Abdomen, (+) Hypoactive Bowel Sounds (+) Generalized tenderness, (+) Nodular liver edge, (+) Lymphadenopathy
Obliterated Traube's Space, (+) Shifting dullness - (-) Crackles, Wheezes
- Extremities: (+) Gr 2 Bipedal Edema - (-) Cyanosis
- Rectal Exam: (+) Skin tag, (+) Black tarry foul- smelling stool
 PWI:
HEPATIC ENCEPHALOPATHY S/T DECOMPENSATED ALCOHOLIC CIRRHOSIS, PORTAL HYPERTENSION with VARICEAL
HEMORRHAGE R/O SBP

Most likely Least likely

Loss, of consciousness, (+) altered sleeping pattern,(+) drowsy&tired, (+) anorexia, (+) Normal liver span, no hematochezia, no diarrhea, no wheezes, no heaves, no
low grade fever, (+) abdominal pain, (+) alcoholic, thrills, no crackles, no cervical lymphadenopathy,
ROS: (+) dizziness, dyspnea, palpitations, melena, constipation, obese
PE: (+) jaundice, icteric sclera, pale palpebral conjunctiva, pale nail bed, gynecomastia, (+)
Dullness on percussion lung, Decreased Breath Sounds on both basal lung fields, (+)
Distended Abdomen, (+) Hypoactive Bowel Sounds (+) Generalized tenderness, (+)
Nodular liver edge, (+) Obliterated Traube's Space, (+) Shifting dullness, (+) Gr 2 Bipedal
Edema

DDx Rule in Rule out

Peptic Ulcer disease
(+)20 pack year smoker, alcoholic beverage drinker, (+)abdominal pain, drowsy and tired (+) abdominal pain not related to food
looking, NSAID use (Ibuprofen & Diclofenac), (+)dizziness, (+)dyspnea during exercise, intake
(+) melena, (+)constipation, (+) anorexia, (+)tachycardia, (+) pale palpebral conjunctiva and (+) dull abdominal pain
nail bed (-) chest pain
(-) hematochezia

Viral Hepatitis Chronic alcoholism, history of blood transfusion, RUQ pain, anorexia, fatigue, malaise, (+) melena, (-) nausea, ), (-) vomiting, (-)
arthritis/joint pain, jaundice, icteric sclerae, gynecomastia, shifting dullness, dizziness, loss malaise, (-) palmar erythema, (-) spider
of consciousness, decreased breath sound, dyspnea, tachypnea angioma
Primary Working
Impression:
Differential
Diagnosis 1
Differential
Diagnosis 2
DIAGNOSTIC
TESTS PLAN RATIONALE

Liver Function Tests ● Assess patient’s serum bilirubin levels, serum albumin and coagulation test (Prothrombin time)
● Assess the biosynthetic capacity of the liver
● International normalized ratio (INR) is often used to express the degree of anticoagulation in patient

Liver Enzymes ● Assess patient’s serum aminotransferases, alkaline phosphatase, and gamma-glutamyl transpeptidase

CBC ● Routine diagnostic test

● Aids in confirming if there is presence of infection, anemia and thrombocytopenia

Abdominal Ultrasound and ● Evaluate the liver parenchyma and to detect extrahepatic manifestations of cirrhosis
CT scan ● Provides information about the appearance of the liver and blood flow within the portal circulation

Ascitic fluid examination ● Aids in assessing patient if there is presence of infection malignancy, portal hypertension and also assess for possible bacterial
(diagnostic paracentesis) peritonitis
● Serum-ascites albumin gradient: sensitive and specific measure to determine whether ascites is related to portal hypertension

Endoscopy (EGD) ● Screening and surveillance for esophagogastric varices must be done in patients with cirrhosis: can also be used to rule in/rule out
PUD
● Modality of choice for the diagnosis and management of bleeding complications associated with chronic liver disease

Serum Creatinine and ● Assess the kidney function Ammonia ● best characterized neurotoxin that precipitates
Electrolytes ● Assess the patient’s Na, K, and Cl hepatic encephalopathy
● Components of MELD score (serum crea and sodium)

Viral Hepatitis ● Rule in/out possible hepatitis infection Liver Biopsy ● Helpful in evaluation of liver cirrhosis but not a
Serologic Assay ● Hepatitis B and C panel requirement