56 yr. old gentleman, Charles Town, WV presented with 3 weeks of anorexia, 2 weeks of abdominal pain, nausea and generalized weakness

Hypotheses: Student to write up a quick list of all possible diagnosis of a gentleman with abdominal pain

HPI: Student to elicit these qualities in the development of the HPI:

o Quality/location of pain – has been constant and mild; gnawing in character (not colicky), starts in mid-epigastrium and goes through to the back

o What alleviates the pain? Bending forward

o What worsens the pain? Does seem somewhat worse after a full meal

o Any fever or chills or systemic signs of illness?

o Has the patient taken any medications, either OTC or Rx to help alleviate the pain

o Has there been weight loss?

o Any blood in bowel movement?

o Any urinary symptoms?

o Constipation hx

PMH

Medical Hx;

o Any hx of DM

o HBP

o Heart disease

o Hepatitis

o Kidney stones

SxHx

o recent CABG x 3 done 8 weeks prior to this illness

General Medical

o Allergies: sulfa-hives

o Meds: metoprolol 100 daily

Altace 5 mg daily

1 baby aspirin per day

OTC meds - Has been using 2 extra strength Tylenol several times a day for past couple weeks for chest wall pain

o Hosp: Pneumonia age 45

Social History

o married for 25 years, 3 kids –one teen at home

o Smoked 2 ppd since age 16

o Usually drinks one or two six packs when he came home from work most of the time, about 4-5 times a week

o Works at Millville quarry, loading stone, blasting stone – whatever needs to be done there

ROS:

• HEENT: Dry mouth
• Resp: No lung complaint – no cough, congestion, no SOB
• CV:Only chest wall pain since surgery
• No anginal pain
• GI: Belly – has felt bloated, nauseated – cut back on food
• Stools seem very light in color
• GU: urine has looked much darker, almost tea-colored
• MS: noticed some joint aches lately
• Itchy skin
• Lost 20 pounds last 2 months

PE

• VS:
• BP = 120/85 P=90 R=16 T=99.3F
• Skin:
• Noticeably jaundiced (patient didn’t appreciate that); looks wan and dull like he’s exhausted
• Spider angiomata on upper chest
• CABG scar is essentially healed, not red
• HEENT:
• Dry mouth/reddened facies
• Icteric sclerae
• Neck: Supple, nontender, normal thyroid, no JVD
• Nodes: No palpable enlarged cervical, axillary, inguinal

• Chest clear
• Heart RRR no murmur
• Abd
• protuberant, but soft;
• + BS
• tender throughout the entire upper abdomen – difficult to locate pain, but seems tender most in middle
• Rectal – neg for mass effect, light-colored stool; heme neg
• M/S = no joint swelling
• Neuro:
• DTR +2/+2 Biceps, Patellar, Achilles; motor

5/5 all ext; CN II=XII intact

o intact touch and vibration;

o normal speech, normal rapid alternating motions and finger to nose pointing,

o Babinski – downgoing (flexor response).

o No tremor or tics.

o Alternate: mild resting tremor

• Mental status- Alert and cooperative but not sure of day or month.

Is oriented to person, year, president, season, and place.

LABS:

• CBC 12,000 with 80 segs, 18 lymphs and 2 monos
• Chem 7 – Glu 280; K+ = 5.0; lytes ok; BUN=58; Creatinine=1.6
• LFT’s = alk phos 425; GGT = 75; bilirubin 4.8 with TB = 3.7
• SGPT = 132; SGOT =125
• H/H = 10/30 – MCV=88;RDW=17

Alternate set labs

• CBC 14,000 with 70 lymphs, 23 segs and 5 monos
• alk phos 130, GGT 50, T Bili 3.0, D.Bili 1.5
• SGPT 1100, SGOT 1200
• H/H = 11/33 with MCV 108
• Chem 7 = Glucose 120, K = 3.8; Na=133 BUN=33; Creatinine=1.1

Student to create their working differential diagnosis list

What does the data tell them so far?

What else do they need to know to make the diagnosis? Imaging studies? Other labs?

What would the student tell the family and patient about the disease state that the patient is exhibiting? What patient ed issues are there?

Remember to instruct the students to detail their thinking process, where they went for their information to help understand the case etc

Appropriate problem list:

• Acute hepatitis – s/p heart pump and blood transfusions 8 weeks prior day of his cardiac cath
• Chronic hepatitis/varices due to long usage of alcohol/stigmata of chronic alcoholic
• Pancreatic tumor with bile duct obstruction
• Gall bladder tumor
• Primary liver tumor
• Liver toxicity secondary to acetaminophen

Student list of learning issues:

• Meaning of increased bilirubin – more increase in direct (conjugated) than indirect (unconjugated)
• **More elevation of alk phos and bili than increase in SGPT and SGOT indicates obstructive process (could be intra-biliary or extrabiliary)
• Hx of alcoholism increases risk of Tylenol toxicity
• ***Recent CABG procedure and cardio-bypass machine increases exposure to viral hepatic agents
• Recent diagnosis of diabetes in past several years may direct one to the pancreas
• ##Meaning of elevated BUN greater than level of creatinine to indicate dehydration
• Does the mild level of anemia indicate a hemolytic process as cause for hyperbilirubinemia? Does the bilirubin breakdown help to include or exclude that?

Alternate case learning issues:

o ** The serum transaminases are elevated > D. Bili and alk phos elevation means an hepatocellular process, not obstructive process.

o *** post transfusion hepatitis includes C and B.

o *** also, post inhalational anesthetic hepatitis is a possibility though very rare with current agents.

o No diagnosis of diabetes

o ##BUN is only slightly elevated with a normal creatinine probably just indicates mild dehydration

o What does the anemia with enlarged MCV mean?

o How does one evaluate acute hepatitis

What imaging may need to be done?

Discuss value of ultrasound and CAT scan of abdomen