The Case of Cirrhosis
Modified from Bruyere's 100 Case Studies in Pathophysiology
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."
S.G. is a 46-year-old 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 15 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.G.'s boss at work had also telephoned her last week concerned about his "unusual and violent behavior on the job."
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)
- History of uncontrolled ascites and peripheral edema
- History of two upper GI hemorrhages from esophageal varices
- History of anemia
- History of E. coli-induced bacterial peritonitis 4 years ago
- History of acute pancreatitis secondary to alcohol abuse
- No history to suggest cardiac or gallbladder disease
- No previous diagnosis of viral or autoimmune hepatitis
SURG
- Status post appendectomy requiring blood transfusions 30 years ago
- Status post open-reduction internal fixation of right femur secondary to MVA 5 years ago
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
SH
- Educated through eighth grade
- Department store men's clothing manager and salesman, 17-year career
- Married for 19 years with 1 daughter, age 10
- History of ethanol abuse, quit 5 years ago following MVA, previously drank 3 cases of beer/week for 15 years
- History of IVDA (heroin) and intranasal cocaine, quit 5 years ago
- Has smoked approximately 1/2 ppd for many years
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 history of non-compliance with his medications
All
NKDA
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
Physical Exam and Lab Tests
Gen
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
- BP 120/75, P 83 and regular (supine)
- BP 118/70, P 80 and regular (standing)
- RR 14 and unlabored
- T 98.8°F orally
- WT 171 lbs
- HT 5 ft-7 in
- SaO2 = 97%
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
- Fundoscopic exam within normal limits
- TMs clear and intact
- Oropharynx 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 within normal limits
- Good air exchange
- (+) gynecomastia
Heart
- Regular rate and rhythm
- Normal S1 and S2 with no S3 or S4
- No murmurs, rubs, or gallops heard
Abd
- Moderately distended, firm, and slightly tender
- (+) prominent veins observed around umbilicus
- (+) hepatosplenomegaly
- Active bowel sounds
- (-) 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
- Cranial nerves grossly intact
- Brisk deep tendon reflexes at 2+
- Slight asterixis noted
- Strength is equal bilaterally
- Confused and disoriented
- Negative Babinski
- Sensory grossly intact
Laboratory Blood Test Results
Patient Case Table 18.1 Laboratory Blood Test Results
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 ĂŽÂĽg/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 ĂŽÂĽg/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