Cirrhosis Case Study Patient’s Chief Complaints Provided

Cirrhosis Case Study Patient’s Chief Complaints Provided by wife: “My husband’s very confused and he has been acting strangely. This morning, he couldn’t answer my questions and seemed not to recognize me. I think that his stomach has been swelling up again, too. He stopped drinking four years ago, but his cirrhosis seems to be getting worse.” History of Present Illness (HPI) S. Green is a 51 yr. 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 confusion. He has unintentionally gained 20 lbs. during the past four weeks. According to his wife, the patient has not been sleeping well for several weeks, has been feeling very lethargic for the past three days, can’t seem to remember appointments lately, and, uncharacteristically, has lost his temper with her several times in the last month. S. Green’s boss at work had also telephoned her last week concerned about his “unusual and violent behavior on the job as a computer engineer.” Past Medical History (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 H/O anemia • H/O 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 Surgery S/P appendectomy requiring blood transfusions 30 years ago S/P open-reduction internal fixation of right femur secondary to MVA 5 years ago Family History (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 Psycho/Social: Married X19 years with one daughter aged 12years Educated with MS degree in Informatics Employed as computer engineer X 18 years H/O ethanol abuse X 25 yrs., quit 5 years ago following MVA and DUI conviction, previously drank 1 cases of beer/day on weekdays and more on weekends X 25 years H/O IVDA (heroin) and intranasal cocaine X 20 years, quit 5 years ago following MVA Has smoked approximately 1 pack of cigarettes per day X 30years 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 Review of Systems: 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 General Appearance The patient is restless, mildly jaundiced, and disoriented to time, place, and people. He is slow to answer questions and his answers make little sense. He is ill-appearing but in no obvious distress Vital Signs T 98.8°F orally BP 120/75, P 83 and regular (supine) BP 118/70, P 80 and regular (standing) RR 14 and unlabored O2sat 95% WT 171 lbs. HT 5 ft-7 in Denies Pain Allergy: NKDA Physical Exam (PE) 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 S1 and S2 with no S3 or S4 • No m/r/g heard Bru 86 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 Labs: Na 135 meq/L, WBC 4,700/mm3 Mg 1.7 mg/dL K 3.5 meq/L PT 15.6 sec AFP 90 ng/mL Cl 101 meq/L PTT 45.1 sec HBsAg (-) HCO3 25 meq/L NH3 250 µg/dL HIV (-) BUN 12 mg/dL AST 107 IU/L Anti-HCV (+) Cr 0.6 mg/dL ALT 86 IU/L HCV RNA 2.8 million/mL Glu, fasting 90 mg/dL Alk Phos 224 IU/L ANA (-) Hb 14.0 g/dL Bilirubin 2.4 mg/dL Fe 75 µg/dL Hct 39.7% Protein 6.6 g/dL Ferritin 200 ng/mL MCV 90 fL Alb 2.7 g/dL Transferrin saturation 38% Plt 34,500/mm3 Ca 8.5 mg/dL Ceruloplasmin 37 mg/dL 25. What referrals would you suggest for this patient upon discharge?_________________________

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