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Case For Small Group Discussion For Students

This patient presented with yellow discoloration of the eyes and skin for two days. Her history revealed chronic alcohol use and recent weight loss. On physical exam, she appeared jaundiced with an enlarged tender liver. Laboratory tests showed elevated bilirubin, AST, ALT and alkaline phosphatase consistent with hepatocellular injury. Based on the history of alcohol use and exam findings, the working diagnosis is alcoholic hepatitis.

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142 views4 pages

Case For Small Group Discussion For Students

This patient presented with yellow discoloration of the eyes and skin for two days. Her history revealed chronic alcohol use and recent weight loss. On physical exam, she appeared jaundiced with an enlarged tender liver. Laboratory tests showed elevated bilirubin, AST, ALT and alkaline phosphatase consistent with hepatocellular injury. Based on the history of alcohol use and exam findings, the working diagnosis is alcoholic hepatitis.

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Muhmd shiyas.H
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We take content rights seriously. If you suspect this is your content, claim it here.
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CASE FOR SMALL GROUP DISCUSSION

CHIEF COMPLAINT: My eyes are yellow for two days.

HISTORY OF PRESENT ILLNESS:

Ms. DK is a 36 year old, unemployed attorney who presents with yellow discoloration of
her eyes which she noticed two days ago while washing her face. At first, she thought
the color was due to the lighting in her bathroom, but this morning, when going outside
of her house to retrieve the mail, she thought her hands "looked yellow."

Ms. DK further admits to feeling "sick and tired" for the past 2 -3 weeks. She has lost
her appetite and feels weak. During this time, she has been frequently nauseated and
ate very little food. Last night, she developed a fever and "shook all over with a chill."
This morning, she awoke after a restless night with pain and a sensation of fullness in
the right upper abdomen. She also vomited twice. The emesis was non -bloody. She
has not had diarrhea. She has no back or shoulder pain. She thinks she lost 20 lbs.
during the last 3 months. She denies having joint pain or skin rash.

Ms. DK is a chronic alcoholic who has been hospitalized on several occasions for
alcohol-related problems, including a psychiatric admission, although she was
considered a gifted, young attorney with a bright future. Since graduation from law
school, she has had many alcohol-related work problems and lost her position at a
prestigious firm three weeks ago. Since that time, she has consumed approximately one
fifth of vodka every day or so.

She is estranged from her husband but is having an affair with a man who uses IV
drugs and has a history of hepatitis. She states she does not use IV drugs. She takes
Tylenol for frequent headaches but takes no other medications. She smokes one pack
of cigarettes per day. She had a spontaneous abortion at age 28 which required
hospitalization but she can't remember if she had a blood transfusion. Last year, she
went to Mexico with her boyfriend.

PHYSICAL EXAMINATION:

The patient is alert but haggard looking. She is skinny and shows prominent cheek
bones. Her clothing is dishevelled and her hair is uncombed. She appears much older
than her stated age.

Vital signs: BP = 104/60 mmHg, HR = 110/minute and regular and full bounding, RR =
18/minute, Temp = 38.90C.

HEENT: Bilateral, deep conjunctival icterus.


CHEST: Prominent ribs. Lungs are clear to percussion and auscultation.

CARDIOVASCULAR: Soft S1 and S2. No murmurs or extra cardiac sounds.

ABDOMEN: The abdomen is round and slightly tympanitic. The liver is palpable beneath
the costal margin (9 cm.) and tender. The liver span is 20 cm. There is no rebound
tenderness, shifting dullness or splenomegaly. Normal bowel sounds.

SKIN: Icteric; spider nevi noted on shoulders.

EXTREMITIES: Bilateral tremors of hands; bilateral palmar erythema.

MUSCLE STRENGTH: 5/5 on all levels

CNS: Within normal limits

LABORATORY DATA:

Complete blood cell count

o White blood cell count: 17,000 cells/mm3 with modest shift to left
o Hemoglobin 10.6 g/dL; Hematocrit 33%
o Platelets 120,000/mm3
o MCV 110/micro m3

Blood Chemistries

o Aspartate arninotransferase (AST) 150 U/L


o Alanine aminotrasferase (ALT) 60 U/L
o Total Bilirubin 22 mg/dL
o Alkaline phosphatase 400 U/L
o albumin = 30 g/L [35-50 g/L]

Prothrombin time 13.2 seconds

During hospitalization: WBC rose to 42,000/mm3; total bilirubin rose to 32 mg/dL


QUESTIONS:

Based on the case presented, answer the following questions:

1. Identify salient historical information that may have a bearing to this patient's chief
complaint and indicate its significance.

2. What is your working diagnosis for her jaundice based on the history?

3. Identify salient physical findings that may have a bearing to this patient's chief
complaint and indicate its significance.

4. What is your working diagnosis for her jaundice based on the history and physical?

5. Identify salient laboratory findings that may have a bearing to this patient's chief
complaint and indicate its significance.

6. Cite the main clinical problem.

7. Cite other significant clinical problems.

8. We need a clear understanding of bilirubin metabolism to solve clinical problems


related to it. Briefly review the formation of bilirubin. Do you think this patient has
unconjugated or conjugated hyperbilirubinemia and why? Is it hepatocellular or
cholestatic and why?

9. Discuss the differential diagnoses based on disease categories. A good way to


discuss this question is to approach the jaundiced patient according to the fractionation
of the bilirubin.

10. How do you classify jaundice according to the mechanism?

11. Now after listing differential diagnosis, what are the important historical information
you should gather from history and why? What are the important physical findings you
should gather from physical examination and why?

12. What are the useful lab studies in evaluation of a patient with jaundice and their
utility? What pathophysiologic process does the laboratory data suggest?

13. What is the diagnosis in this patient?

14. Cite data from the history, physical exam and laboratory to support this diagnosis.

15. What other laboratory/radiologic examinations might be done to exclude other


causes of jaundice?
16. Is liver biopsy needed? Granting that a liver biopsy was taken, what would a liver
biopsy show in this patient?

17. What advice would you give the patient regarding the use of Tylenol?

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