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Module 7 Case 2

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15 views2 pages

Module 7 Case 2

Uploaded by

herinofgrun4
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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DEPARTMENT OF SURGERY

3RD YEAR A.Y. 2024-2025


Chairman: Dr. Jan Michael V. Yap
Vice Chairman: Dr. Manfred Tabilog
Regular Faculty: Dr. Jon Francis Co, Dr. Dale Ross Duran, Dr. Dr. Nielsen Flordeliz, Dr. Michael Alan Simporios, Dr. Eloise
Ana Suan, Dr. Jessa Christine Surban-Vergara, Dr. Carlos Antonio Go

MODULE 7: LIVER
CASE 2

P.S., a 45-year-old male arrived to the Emergency Department with a chief complaint of hematemesis. Initially, he
presented with the primary symptoms of dizziness and vomiting, which had been troubling him significantly. Clinically,
the patient exhibited signs of hematemesis, having experienced two episodes within the past week, along with melena.
He reported that these distressing symptoms had begun within the last month, indicating the recent onset of his current
health issues.

The patient’s medical history revealed a long-standing history of chronic alcohol consumption spanning many years.
Specifically, he consistently consumed 120 ml of alcohol daily, according to the detailed account of his history. In
addition to his alcohol consumption, the patient was diagnosed with anemia a year ago, a condition that has likely
impacted his overall health. Notably, there was no history of diabetes, heart disease, or asthma. Furthermore, the
patient had no history of any gastrointestinal surgeries or other significant surgical interventions, indicating that he had
not undergone any major procedures that could have contributed to his current health status.

His mother was a known Diabetic, and his father died of Colon Cancer.

On Physical Examination:
Vital signs:
- BP: 70/60mmHg
- HR: 110bpm
- RR: 28cpm
- Temp: 38C
CNS: disoriented
Skin: pale, jaundiced
HEENT: icteric sclerae, no cervical lymphadenopathy
C/L: Clear breath sounds, Equal chest expansion
CV: adynamic pericardium
Abdomen: distended (+) shifting dullness, liver palpable 4cm below costal margin, (+) enlarged, swollen veins across the
abdomen
Extremities: feint peripheral pulses, CRT >2secs

GUIDE QUESTIONS (GUIDE FOR PPT PRESENTATION)


1. Clearly present the patient’s information:
a. General Data
b. Chief complaint
c. History of Present Illness
d. Past medical history
e. Personal and social history
f. Family history
2. Clearly present the patient’s physical exam findings and its interpretation
3. What are the case’s salient features
4. Based on the history and PE, what is your complete Primary Impression
5. What are your Differential Diagnosis? At least 3

Work-up was done which revealed:


CBC Alkaline phosphatase: 200 U/ Ml (normal 35 to 196 U/mL)
- Wbc 16,000
o Leukocytes 80% Alanine aminotransferase: 103 U/mL (normal 10-56U/mL)
- Hgb: 7
- Hct 22 Aspartate aminotransferase: 103 U/mL (normal 10-56
- Platelet: 50, 000 U/mL)

Total Bilirubin: 3.2 mg/ dL

Albumin: 2g/dL

Prothrombin time: 7secs


INR: 2.8

Endoscopy:

Engorged, tortuous esophageal vessels.

GUIDE QUESTIONS (GUIDE FOR PPT PRESENTATION)


1. Interpret the results. Based on the patient’s work-up, what is your final impression
a. Include the patient’s Child’s-Pugh score
2. Discuss the patient’s case
a. Anatomy and physiology of the liver
b. Evaluation of Hepatobiliary diseases
c. Pathophysiology of the patient’s condition/diagnosis
d. How will you manage this patient? (Non-surgical and Surgical Options)

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