Medical Grand Rounds Clinical Vignette医疗查房的临床小插曲.pptVIP

Medical Grand Rounds Clinical Vignette Matthias C. Kugler, M.D. Internal Medicine Resident 09-12-2008 Chief Complaint 53 year old Caucasian male with Hepatitis C and cirrhosis, who presented to Bellevue Hospital with 8 days of abdominal pain and increasing girth History of Present Illness Right Upper Quadrant pain for 8 days, up to 8/10 intensity, aching, non-radiating, intermittent, lasting several hours, no association with nausea or vomiting. Increasing girth and abdominal swelling. He denied fever or chills History Past Medical History: Hepatitis C diagnosed 15 years ago, cirrhosis since 2003, awaiting transplant Esophageal varices with endoscopic banding 2006 Past Surgical History: none Family History: non-contributory Allergies: Penicillin – rash Medications: Esomeprazole 40mg daily, Furosemide 40mg daily, Aldactone 25mg daily, Lactulose 30ml bid, Propanolol 20mg tid, Acetaminophen 500mg q6h prn pain, Docusate 100mg tid Social History: no toxic habits, married, 2 children, no intravenous drug use ROS: otherwise negative Physical Examination General: Ill-appearing white male in mild distress, alert and oriented x 3 Vital Signs: BP-113/80 HR-65 RR-20-22 O2-sat 93% (room air) Temp-37.0°C Head/Neck: + scleral icterus Lungs: breath sounds decreased b/l bases, upper lungs clear to auscultation Abdominal: + tense, distended, diffusely tender to palpation, + fluid wave, no guarding or rebound, bowel sounds hypoactive in all 4 quadrants Extremities: 1-2+ pitting edema of the legs bilaterally Skin: + jaundice Remainder of physical exam normal Laboratory Values Hepatic: AST 100 (7-27) ALT 43 (1-21) AP 112 (13-39) Tbili 7.7 (1.0) DBili 5.1 (0.4) Prot 10.3 (6.0-8.4) Alb 1.6 (3.5-5.0) CBC: WBC 4.2 (N53%, L26%, M15%, E5%) Hb 11.1 (13-18) Hct 31.6 (35-50) MCV 112 (86-98) plt 81 (150-350) Coags: INR 2.5 (1.15) PTT 52 (25-38) Basic: Na 132 (140-145) ABG: pH 7.43, pCO2 39, pO2 87, HCO- 26, O2-