Cirrhosis Case Study Patient: Lisa History of
Cirrhosis Case Study Patient: Lisa History of present illness: You are caring for Lisa Ramsey, a 47-year-old Caucasian female who works in the hospitality industry. She arrived at the ED complaining of hematemesis, nausea, and abdominal distention. She reports feeling “sick” for a while and has a temperature of 39.2°C, is intermittently confused and is accompanied by her husband, Ken. She has not vomited since being in the ED. Social History: (from her husband, Ken) Ken and Lisa own a restaurant downtown and spend most of their time there as they do not have any children together. Lisa is a trained bartender and Ken manages the restaurant on the business end. Ken denies that Lisa has a drinking problem but does confirm she drinks a “bottle or two” of wine every evening. Medical: ETOH use, HTN, hysterectomy 15 years ago. Subjective History: (from Ken): Lisa has put all of her time and effort into the business since she was 32 years old. Ever since Lisa found out she could not carry children and had a total hysterectomy, she focused more on her career. Lisa has been drinking more over the past five years or so. Ken noticed that Lisa has been acting “off” the past few weeks but attributed it to stress. She has become more intermittently confused and forgetful. Ken finally decided to bring Lisa into the hospital once he noticed she vomited blood. Her last known alcoholic drink was one day ago. Medications: None Orders: NPO now and then Low sodium diet 2G per day Diuretic therapy Abstinence from alcohol Antibiotic therapy Avoid hepatotoxins Frequent record of vital signs Measure and record the nature, time, and amount of vomitus Diagnostic Test Results LFTs AST: 40 U/mL ALT: 30 U/mL CBC WBC: 26,000/mm3 Neutrophils: 25,000/mm3 Lymphocytes: 4,000/mm3 Monocytes: 600/mm3 Eosinophils: 300/mm3 Basophils: 100/mm3 RBC: 4.5 X 1012/L Hgb: 8 g/dL HCT: 29% Platelets: 30,000/mm3 Albumin 2.0 g/dL Chemistry BUN: 18 mg/dl Creatinine: 1.0 mg/dl Na: 130 mmol/L K: 4.5 mmol/L Cl: 100 mmol/L Ca: 9.6 mg/dl Glucose: 100 mg/dL Phosphate: 1.0 mmol/L PT/PTT PT: 17 Seconds PTT: 100 seconds INR: 4 Ammonia (plasma) 65 mcg/dL CT abdomen Demonstrates tortuous hepatic arteries in addition to enlarged left lobe and caudate. With an area of focal fibrosis and atrophy of the posterior right lobe. Detects large volumes of fluid. Abdominal/Liver ultrasound Coarsened echo texture and enlarged left lobe of the liver. Liver contour appears nodular. Detects volumes of fluid. Percutaneous Liver Biopsy Micronodular pattern with nodules larger than 3 mm in diameter. The nodules are almost uniform, lack any normal structure and are roughly lobular or sublobular in size. EGD Medium enlarged tortuous esophageal varices that occupy less than 1/3 of the lumen. Paracentesis Large volume aspirated 1500 mL. Samples sent to lab to test for SBP (spontaneous bacterial peritonitis), pending results. Based on the data you gathered throughout this case study, what education would you provide to the family? Make sure to give a strong rationale (WHY?) for the information you provide. 1) Family Education 2) Clinical Significance/Impact 3) What education is essential to communicate to Lisa’s husband right now? 4) What is important to tell the family about alcohol cessation?
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